Provider Demographics
NPI:1134246895
Name:DICKSON, DAVID CARROLL (1CERTIFIED PEDORTHI)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CARROLL
Last Name:DICKSON
Suffix:
Gender:M
Credentials:1CERTIFIED PEDORTHI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 W. SHERIDAN AVENUE
Mailing Address - Street 2:JAY DRUG C. (DCD PEDORTHICS)
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601
Mailing Address - Country:US
Mailing Address - Phone:712-246-2635
Mailing Address - Fax:712-246-3933
Practice Address - Street 1:612 W. SHERIDAN AVENUE
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601
Practice Address - Country:US
Practice Address - Phone:712-246-2635
Practice Address - Fax:712-246-3933
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
IA074625224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN547455800Medicaid