Provider Demographics
NPI:1548020464
Name:DICKERSON, ALEC (DPM)
Entity type:Individual
Prefix:
First Name:ALEC
Middle Name:
Last Name:DICKERSON
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 1:1607 E CRYSTAL DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-2304
Mailing Address - Country:US
Mailing Address - Phone:502-905-2077
Mailing Address - Fax:
Practice Address - Street 1:10500 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-865-1625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program