Healthcare Provider Details

I. General information

NPI: 1215041041
Provider Name (Legal Business Name): PATRICIA A. DICKERSON MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 E ALEX BELL RD
CENTERVILLE OH
45459-2658
US

IV. Provider business mailing address

1299 E ALEX BELL RD
CENTERVILLE OH
45459-2658
US

V. Phone/Fax

Practice location:
  • Phone: 937-436-1117
  • Fax: 937-436-9576
Mailing address:
  • Phone: 937-436-1117
  • Fax: 937-436-9576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA A DICKERSON
Title or Position: OWNER
Credential: MD
Phone: 937-436-1117