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General NPI Number Information
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NPI Number | 1427296318
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Entity Type | Individual
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Provider Name | MISTY IRENE DICKERSON D.O.
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Gender | Female
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Dates
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Enumeration Date | 01/30/2009
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Last Update Date | 12/04/2020
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Provider Practice Location Address
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Address Line | 7740 WASHINGTON VILLAGE DRIVE SUITE 100
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City | CENTERVILLE
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State | OH
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Zip | 45458-3994
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Country | US
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Telephone | 937-531-7900
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Fax | 937-531-7901
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Provider Business Mailing Address
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Address Line | 7740 WASHINGTON VILLAGE DR SUITE 100
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City | CENTERVILLE
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State | OH
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Zip | 45459-4056
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Country | US
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Telephone | 937-531-7900
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Fax | 937-531-7901
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 34.010654
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 34010654
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License Number State | OH
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