Healthcare Provider Details

I. General information

NPI: 1508609215
Provider Name (Legal Business Name): MR. BRIAN DICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

8301 NW 163RD TER
EDMOND OK
73013-6009
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4417
  • Fax:
Mailing address:
  • Phone: 405-777-3628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1508609215
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: