Provider Demographics
NPI:1205902319
Name:DICKERSON, OTIS ADAM (DC)
Entity type:Individual
Prefix:DR
First Name:OTIS
Middle Name:ADAM
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-2938
Mailing Address - Country:US
Mailing Address - Phone:256-383-1468
Mailing Address - Fax:256-383-2132
Practice Address - Street 1:410 N NASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660-2938
Practice Address - Country:US
Practice Address - Phone:256-383-1468
Practice Address - Fax:256-383-2132
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1883111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51505689DICOtherBLUE CROSS BLUE SHIELD
ALU73873Medicare UPIN
AL51505689DICOtherBLUE CROSS BLUE SHIELD