Provider Demographics
NPI:1710974688
Name:DICKERMAN, STUART (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:DICKERMAN
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 1:530 1ST AVE # HCC4D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:646-501-7733
Mailing Address - Fax:
Practice Address - Street 1:530 1ST AVE # HCC4D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:646-501-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163878207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01133059Medicaid
NYD91926Medicare UPIN
NY01133059Medicaid