Healthcare Provider Details

I. General information

NPI: 1194668871
Provider Name (Legal Business Name): MR. DEREK ALLEN DICKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 EARTH RD
ELGIN SC
29045-7114
US

IV. Provider business mailing address

612 ROBERT DANIEL DR APT 6305
DANIEL ISLAND SC
29492-7492
US

V. Phone/Fax

Practice location:
  • Phone: 803-844-5415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: