Provider Demographics
NPI:1699181842
Name:DICKERSON, CHARLES H
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 OLD HENDERSON HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-6457
Mailing Address - Country:US
Mailing Address - Phone:903-596-9729
Mailing Address - Fax:903-747-3373
Practice Address - Street 1:2208 OLD HENDERSON HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-6457
Practice Address - Country:US
Practice Address - Phone:903-596-9729
Practice Address - Fax:903-747-3373
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6309247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0860918-01Medicaid
TX0860918-01Medicaid