Provider Demographics
NPI:1760569149
Name:DICKERSON, J BROOKS (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:BROOKS
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:765-448-8085
Practice Address - Street 1:2600 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3055
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-838-4698
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028572207Q00000X
IN01028572A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100083060Medicaid
IN000000642936OtherANTHEM PROVIDER NUMBER
IN152870AMedicare PIN
IN815500EE1Medicare PIN
080159210Medicare PIN
IN000000642936OtherANTHEM PROVIDER NUMBER
INB28483Medicare UPIN