Provider Demographics
NPI:1861474660
Name:DICKERSON, LEON ARCHIBALD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:ARCHIBALD
Last Name:DICKERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:CREDENTIALING COORDINATOR
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:704-323-3911
Practice Address - Street 1:2001 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1215
Practice Address - Country:US
Practice Address - Phone:704-332-2225
Practice Address - Fax:704-339-1448
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC19049207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8928461Medicaid
SC232637Medicaid
NC205924FMedicare ID - Type Unspecified
SC232637Medicaid