Provider Demographics
NPI:1427296318
Name:DICKERSON, MISTY IRENE (DO)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:IRENE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7740 WASHINGTON VILLAGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4056
Mailing Address - Country:US
Mailing Address - Phone:937-531-7900
Mailing Address - Fax:937-531-7901
Practice Address - Street 1:7740 WASHINGTON VILLAGE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3994
Practice Address - Country:US
Practice Address - Phone:937-531-7900
Practice Address - Fax:937-531-7901
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.010654174400000X
OH34010654207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0076897Medicaid
OHH130943Medicare PIN
OHH130944Medicare PIN