Provider Demographics
NPI:1215908710
Name:DICKSON, BRIAN GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GLENN
Last Name:DICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 S MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3503
Mailing Address - Country:US
Mailing Address - Phone:870-932-1820
Mailing Address - Fax:870-972-6712
Practice Address - Street 1:1010 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3503
Practice Address - Country:US
Practice Address - Phone:870-932-1820
Practice Address - Fax:870-972-6712
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2747207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1215908710OtherMISSOURI MEDICAID
AR142999001Medicaid
AR200041938OtherRAILROAD MEDICARE
AR142999001Medicaid
MO1215908710OtherMISSOURI MEDICAID
AR5L807B814Medicare PIN