Provider Demographics
NPI:1952378184
Name:DICKERMAN, JOEL L (DO)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:L
Last Name:DICKERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:CO
Mailing Address - Zip Code:80809-0490
Mailing Address - Country:US
Mailing Address - Phone:719-471-6512
Mailing Address - Fax:719-572-9033
Practice Address - Street 1:1705 ARBOR WAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-2128
Practice Address - Country:US
Practice Address - Phone:719-471-6512
Practice Address - Fax:719-572-9033
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01298017Medicaid
COC811379Medicare PIN
B52428Medicare UPIN
CB3008Medicare ID - Type Unspecified
COB4712Medicare PIN