Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | SC001379L | PA |
Y | 222Z00000X | Podiatrist | SC001379L | PA |
NPI | 1003885120 |
---|---|
Provider Name | Mr. Walter Dale Dickson |
First Address | Ellwood City, PA 16117 |
Second Address | Ellwood City, PA 16117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 22/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P00472622 | PALMETTO GBA - RAILROAD MEDICARE (01) | PA |
T27585 | (02) |