Healthcare Provider Details

I. General information

NPI: 1174782288
Provider Name (Legal Business Name): MICHAEL DICKERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 N ST # 8975
SACRAMENTO CA
95816-5712
US

IV. Provider business mailing address

2108 N ST # 8975
SACRAMENTO CA
95816-5712
US

V. Phone/Fax

Practice location:
  • Phone: 415-251-5830
  • Fax: 415-276-5758
Mailing address:
  • Phone: 415-251-5830
  • Fax: 415-276-5758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number107976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: