Healthcare Provider Details

I. General information

NPI: 1023004512
Provider Name (Legal Business Name): JAMES WILEY DICKERSON III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HILYARD ST SUITE S-460
EUGENE OR
97401-8122
US

IV. Provider business mailing address

PO BOX 24410
EUGENE OR
97402-0451
US

V. Phone/Fax

Practice location:
  • Phone: 541-685-1794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD150778
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1020407
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: