Provider Demographics
NPI:1134190697
Name:DICKINSON, RODGER C JR (MD)
Entity type:Individual
Prefix:
First Name:RODGER
Middle Name:C
Last Name:DICKINSON
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 1:1504 SE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3988
Mailing Address - Country:US
Mailing Address - Phone:479-273-1111
Mailing Address - Fax:479-273-1255
Practice Address - Street 1:1504 SE 28TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3988
Practice Address - Country:US
Practice Address - Phone:479-273-1111
Practice Address - Fax:479-273-1255
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4563207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126591001Medicaid
MO207996307Medicaid
MO207996307Medicaid
AR126591001Medicaid