Provider Demographics
NPI:1942422449
Name:DICKSON, BRADLEY EARL (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:EARL
Last Name:DICKSON
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 1:4079 B GANTZ RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4912
Mailing Address - Country:US
Mailing Address - Phone:614-875-3444
Mailing Address - Fax:614-875-7780
Practice Address - Street 1:4079 B GANTZ RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-4912
Practice Address - Country:US
Practice Address - Phone:614-875-3444
Practice Address - Fax:614-875-7780
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065323208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHIO1200779OtherUHC
OHIO000000122737OtherANTHEM