Provider Demographics
NPI:1700819679
Name:DICKERSON, JOHN HENRY III (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HENRY
Last Name:DICKERSON
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 E 4TH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2800
Mailing Address - Country:US
Mailing Address - Phone:248-584-4222
Mailing Address - Fax:248-584-2225
Practice Address - Street 1:830 E 4TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2800
Practice Address - Country:US
Practice Address - Phone:248-584-4222
Practice Address - Fax:248-584-2225
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006942111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950F353760OtherBCBS
MI4177350Medicaid
MIOM22720Medicare ID - Type Unspecified
MI950F353760OtherBCBS