Provider Demographics
NPI:1093694119
Name:DICKERSON, COLTON
Entity type:Individual
Prefix:
First Name:COLTON
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:43314-7723
Mailing Address - Country:US
Mailing Address - Phone:567-240-2451
Mailing Address - Fax:
Practice Address - Street 1:1199 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6475
Practice Address - Country:US
Practice Address - Phone:740-736-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTY824496175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist