Healthcare Provider Details

I. General information

NPI: 1033440342
Provider Name (Legal Business Name): MALCOLM J. DICKERSON, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W 4TH ST
ELDON MO
65026-1919
US

IV. Provider business mailing address

411 W 4TH ST
ELDON MO
65026-1919
US

V. Phone/Fax

Practice location:
  • Phone: 573-392-9200
  • Fax: 573-392-4626
Mailing address:
  • Phone: 573-392-9200
  • Fax: 573-392-4626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR5N38
License Number StateMO

VIII. Authorized Official

Name: MS. VICKI JO ROUTON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 573-392-9200