Provider Demographics
NPI:1699777854
Name:DICKERSON, GREGG ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ALAN
Last Name:DICKERSON
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 1:10542 LIETER PL
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-9786
Mailing Address - Country:US
Mailing Address - Phone:303-506-4753
Mailing Address - Fax:
Practice Address - Street 1:1514 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3248
Practice Address - Country:US
Practice Address - Phone:662-332-6150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17812174400000X
CO475862085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS10781438OtherUNITEDHEALTHCARE CAQH
MN896610OtherUSA MANAGED CARE ORG
E09498Medicare UPIN
MN896610OtherUSA MANAGED CARE ORG
MSE09498Medicare UPIN