Provider Demographics
NPI:1255412052
Name:DICKERSON, TASHA BROOKS (MD)
Entity type:Individual
Prefix:DR
First Name:TASHA
Middle Name:BROOKS
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 N 28TH ST
Mailing Address - Street 2:STE 300
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-5332
Mailing Address - Country:US
Mailing Address - Phone:804-225-7177
Mailing Address - Fax:804-225-7176
Practice Address - Street 1:304 E LEIGH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1410
Practice Address - Country:US
Practice Address - Phone:804-225-7148
Practice Address - Fax:804-225-7159
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010185505Medicaid
VA98690OtherPTTIMAFAMILYCARE
VA010185505OtherVA PERMIER
VA186776OtherANTHEM BC/BS
VA541588928OtherAETNA
VA329716OtherSOUTHERNHEALTH
VA9401772OtherPHCS
VA541588928OtherCIGNA
VA57114OtherCARENET
VA10185505VOtherVCC
VAC03251OtherMCR GROUP
VA008782D51Medicare ID - Type Unspecified
VA541588928OtherAETNA