Provider Demographics
NPI:1396801692
Name:DICKERSON, DAVID P (D C)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2223
Mailing Address - Country:US
Mailing Address - Phone:405-273-6822
Mailing Address - Fax:888-413-2901
Practice Address - Street 1:3705 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2223
Practice Address - Country:US
Practice Address - Phone:405-273-6822
Practice Address - Fax:888-413-2901
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2916111N00000X
OK4127111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC26033OtherMEDICARE LEGACY
CO26033Medicare ID - Type Unspecified
COC26033OtherMEDICARE LEGACY