Provider Demographics
NPI:1760599815
Name:DICKERT, BENJAMIN C (DPM)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:DICKERT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 CAREW ST
Mailing Address - Street 2:STE 101
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-4105
Mailing Address - Country:US
Mailing Address - Phone:413-736-3225
Mailing Address - Fax:413-736-3382
Practice Address - Street 1:222 CAREW ST
Practice Address - Street 2:STE 101
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-4105
Practice Address - Country:US
Practice Address - Phone:413-736-3225
Practice Address - Fax:413-736-3382
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPD1884213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0362663Medicaid
MA0774440001OtherMEDICARE DMERC
MAY78037Medicare PIN
MA0774440001OtherMEDICARE DMERC
T58811Medicare UPIN