MEDICARE: DR. JAMES A DICKEY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WC0802X	Corneal and Contact Management Optometrist	1234	NE
2	152W00000X	Optometrist	1234	NE
3	152W00000X	Optometrist	3342	OH
4	152WC0802X	Corneal and Contact Management Optometrist	3342	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	07163	OTHER	NE	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1508861006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES A DICKEY O.D.

Provider Business Mailing Address
First Line	:	1516 COMMONS DR
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-7805
Country	:	US
Telephone Number	:	308-430-1305
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 ARLINGTON RD
Second Line	:	SUITE B
City	:	BROOKVILLE
State	:	OH
Zip	:	45309-1103
Country	:	US
Telephone Number	:	937-770-1265
Fax Number	:	937-770-1268

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	08/12/2013

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