Healthcare Provider Details

I. General information

NPI: 1780119867
Provider Name (Legal Business Name): JUSTIN DENHART DICKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

9201 W THOMAS RD
PHOENIX AZ
85037-3332
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-0387
  • Fax:
Mailing address:
  • Phone: 623-327-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number011468
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.013591
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: