Provider Demographics
NPI:1689888356
Name:DICKERSON, WESLEY J (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:J
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 4TH AVE
Mailing Address - Street 2:#9J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4906
Mailing Address - Country:US
Mailing Address - Phone:646-812-8368
Mailing Address - Fax:
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2054
Practice Address - Country:US
Practice Address - Phone:718-245-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOBB4745785-20050182302084P0800X
NY251879-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry