Provider Demographics
NPI:1902843154
Name:DICKENS, MARIO S (DPM)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:S
Last Name:DICKENS
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 1:6116 SHALLOWFORD RD
Mailing Address - Street 2:STE 118
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7201
Mailing Address - Country:US
Mailing Address - Phone:423-710-1224
Mailing Address - Fax:423-710-1228
Practice Address - Street 1:6116 SHALLOWFORD RD
Practice Address - Street 2:STE 118
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7201
Practice Address - Country:US
Practice Address - Phone:423-710-1224
Practice Address - Fax:423-710-1228
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN690213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4342355Medicaid
P00744501OtherRAILROAD MEDICARE
TN1512827Medicaid
MIU86885Medicare UPIN
MI4342355Medicaid
TN33500152Medicare PIN
P00744501OtherRAILROAD MEDICARE
GA202I484339Medicare PIN