Provider Demographics
NPI:1174581227
Name:DICKMAN, JEROME IVAN (MD)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:IVAN
Last Name:DICKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:33 SADDLEBOW RD
Mailing Address - Street 2:
Mailing Address - City:BELL CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1137
Mailing Address - Country:US
Mailing Address - Phone:818-884-5121
Mailing Address - Fax:818-999-0275
Practice Address - Street 1:33 SADDLEBOW RD
Practice Address - Street 2:
Practice Address - City:BELL CANYON
Practice Address - State:CA
Practice Address - Zip Code:91307-1137
Practice Address - Country:US
Practice Address - Phone:818-884-5121
Practice Address - Fax:818-999-0275
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21070207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A210700Medicaid
CA00A210700Medicaid