Provider Demographics
NPI:1861499485
Name:DICKERSON, PAUL W (DC, LTD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DC, LTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 S ALMA SCHOOL RD STE 354
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3028
Mailing Address - Country:US
Mailing Address - Phone:480-726-2287
Mailing Address - Fax:888-316-9272
Practice Address - Street 1:20860 N TATUM BLVD STE 290
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4282
Practice Address - Country:US
Practice Address - Phone:480-563-1144
Practice Address - Fax:480-563-2371
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-29
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4412111NN0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ76268Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
AZT67104Medicare UPIN
AZ76267Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE