Provider Demographics
NPI:1023774908
Name:DICKERSON, DIONYSOS DURAND (RPFT)
Entity type:Individual
Prefix:
First Name:DIONYSOS
Middle Name:DURAND
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:RPFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21081 TEEPEE RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-8318
Mailing Address - Country:US
Mailing Address - Phone:740-740-3893
Mailing Address - Fax:
Practice Address - Street 1:3490 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3105
Practice Address - Country:US
Practice Address - Phone:740-740-3893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
137535227900000X
2279P1005X, 2279P1006X, 2279P1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P1004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary Diagnostics
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
No2279P1005XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary Rehabilitation
No2279P1006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary Function Technologist