Provider Demographics
NPI:1164480620
Name:DICKIESON, WILLIAM (DPM)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:DICKIESON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 MASON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2841
Mailing Address - Country:US
Mailing Address - Phone:313-561-2446
Mailing Address - Fax:
Practice Address - Street 1:1213 MASON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2841
Practice Address - Country:US
Practice Address - Phone:313-561-2446
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001040213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIWD001040OtherBLUE CROSS LICENSE
MI2120106Medicaid
MIT34317Medicare UPIN
MIWD001040OtherBLUE CROSS LICENSE