Provider Demographics
NPI:1851314017
Name:DICKSON, ROBERT W III (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:DICKSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 MAIN STREET
Mailing Address - Street 2:PO BOX 110
Mailing Address - City:SHILOH
Mailing Address - State:NJ
Mailing Address - Zip Code:08353-0110
Mailing Address - Country:US
Mailing Address - Phone:856-455-1464
Mailing Address - Fax:856-455-6381
Practice Address - Street 1:851 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:NJ
Practice Address - Zip Code:08353-8505
Practice Address - Country:US
Practice Address - Phone:856-455-1464
Practice Address - Fax:856-455-6381
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA53365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJJ2232OtherHORIZON
NJ4540603Medicaid
NJE78421Medicare UPIN
NJ4540603Medicaid