Provider Demographics
NPI:1760097968
Name:DICKERSON, DANIEL J
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
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 1:4283 S SODOM BALLOU RD
Mailing Address - Street 2:
Mailing Address - City:CASSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45312-8701
Mailing Address - Country:US
Mailing Address - Phone:937-418-1397
Mailing Address - Fax:
Practice Address - Street 1:4283 S SODOM BALLOU RD
Practice Address - Street 2:
Practice Address - City:CASSTOWN
Practice Address - State:OH
Practice Address - Zip Code:45312-8701
Practice Address - Country:US
Practice Address - Phone:937-418-1397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
OH5504592253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care