Provider Demographics
NPI:1295916153
Name:WALTER D. DICKSON DPM
Entity type:Organization
Organization Name:WALTER D. DICKSON DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:724-758-5564
Mailing Address - Street 1:310 STATE ROUTE 288
Mailing Address - Street 2:
Mailing Address - City:ELLWOOD CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16117-5544
Mailing Address - Country:US
Mailing Address - Phone:724-758-5564
Mailing Address - Fax:724-758-6251
Practice Address - Street 1:310 STATE ROUTE 288
Practice Address - Street 2:
Practice Address - City:ELLWOOD CITY
Practice Address - State:PA
Practice Address - Zip Code:16117-5544
Practice Address - Country:US
Practice Address - Phone:724-758-5564
Practice Address - Fax:724-758-6251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001379-L332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0768510001Medicare NSC
PA048678Medicare PIN