MEDICARE: DR. OTTO FREDERICK DICKMAN IV M.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	207Q00000X	Family Medicine Physician	495-6304-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619065943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OTTO FREDERICK DICKMAN IV M.D.

Provider Business Mailing Address
First Line	:	PO BOX 607
Second Line	:	EMERY MEDICAL CENTER
City	:	CASTLE DALE
State	:	UT
Zip	:	84513-0607
Country	:	US
Telephone Number	:	435-381-2305
Fax Number	:	435-381-4535

Provider Business Practice Location Address
First Line	:	90 WEST MAIN
Second Line	:	EMERY MEDICAL CENTER
City	:	CASTLE DALE
State	:	UT
Zip	:	84513-0607
Country	:	US
Telephone Number	:	435-381-2305
Fax Number	:	435-381-4535

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/09/2007

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