Healthcare Provider Details

I. General information

NPI: 1891796868
Provider Name (Legal Business Name): RICHARD S DICKMEYER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date: 03/22/2006
Reactivation Date: 03/30/2006

III. Provider practice location address

1270 E STATE ROAD 205 SUITE 240
COLUMBIA CITY IN
46725-9499
US

IV. Provider business mailing address

1234 E DUPONT RD SUITE 3
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-244-7600
  • Fax: 260-244-5212
Mailing address:
  • Phone: 260-373-9700
  • Fax: 260-373-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01029443
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: