Healthcare Provider Details

I. General information

NPI: 1326309196
Provider Name (Legal Business Name): CLINTON DONALD DICKERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 DANTIGNAC ST
AUGUSTA GA
30901-2788
US

IV. Provider business mailing address

9 OAKLEAF DR
NORTH AUGUSTA SC
29860-9721
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-0600
  • Fax:
Mailing address:
  • Phone: 803-292-8227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number074576
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: