Provider Demographics
NPI:1972583094
Name:DICKINSON, LARRY J (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E JOHNSON ST
Mailing Address - Street 2:PO BOX 98
Mailing Address - City:GALLATIN
Mailing Address - State:MO
Mailing Address - Zip Code:64640-1338
Mailing Address - Country:US
Mailing Address - Phone:660-663-2800
Mailing Address - Fax:660-663-3707
Practice Address - Street 1:100 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:MO
Practice Address - Zip Code:64640-1338
Practice Address - Country:US
Practice Address - Phone:660-663-2800
Practice Address - Fax:660-663-3707
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240880708Medicaid
MOE43707Medicare UPIN
MO0003526Medicare ID - Type Unspecified