Provider Demographics
NPI:1891796868
Name:DICKMEYER, RICHARD S (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:S
Last Name:DICKMEYER
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:1270 E STATE ROAD 205
Practice Address - Street 2:SUITE 240
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-9499
Practice Address - Country:US
Practice Address - Phone:260-244-7600
Practice Address - Fax:260-244-5212
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-09-24
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
IN01029443207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351972384039OtherTRICARE
INP00467073OtherRAILROAD MEDICAE
IN3937240025OtherMEDICARE DMEPOS
IN1229OtherPHP
IN100263110AMedicaid
IN000000325785OtherANTHEM
IN000000570550OtherANTHEM
IN1977073OtherCIGNA
IN4048678OtherAETNA
INIC25982Medicare UPIN
IN4048678OtherAETNA
IN000000570550OtherANTHEM
IN1229OtherPHP