Provider Demographics
NPI:1942243712
Name:DICKERSON, QUINTON HOWARD JR (MD)
Entity Type:Individual
Prefix:
First Name:QUINTON
Middle Name:HOWARD
Last Name:DICKERSON
Suffix:JR
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 1:970 LAKELAND DR
Mailing Address - Street 2:SUITE 61
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4635
Mailing Address - Country:US
Mailing Address - Phone:601-982-7850
Mailing Address - Fax:601-718-5145
Practice Address - Street 1:970 LAKELAND DR
Practice Address - Street 2:SUITE 61
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4635
Practice Address - Country:US
Practice Address - Phone:601-982-7850
Practice Address - Fax:601-718-5145
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5261207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00014082Medicaid
MS00014082Medicaid
MS060000031Medicare PIN