Provider Demographics
NPI:1184615700
Name:DICKERSON, BRADFORD CLARK (MD)
Entity type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:CLARK
Last Name:DICKERSON
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 1:149 13TH ST
Mailing Address - Street 2:SUITE 2691
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-2020
Mailing Address - Country:US
Mailing Address - Phone:617-724-6557
Mailing Address - Fax:617-726-5760
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:WACC 835
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2160842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2018811Medicaid
MAJ26662OtherBCBS MA
MA216084OtherTUFTS HEALTH PLAN
MA2018811Medicaid
MA216084OtherTUFTS HEALTH PLAN