Healthcare Provider Details

I. General information

NPI: 1851950257
Provider Name (Legal Business Name): STEVEN DANIEL DICKERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 GRAND AVE STE 106
SAN MARCOS CA
92078-2450
US

IV. Provider business mailing address

150 VALPREDA RD
SAN MARCOS CA
92069-2973
US

V. Phone/Fax

Practice location:
  • Phone: 760-736-6767
  • Fax:
Mailing address:
  • Phone: 760-736-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5874
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: