Provider Demographics
NPI:1487120119
Name:DICKERSON, MILTON AMIS (DPT)
Entity type:Individual
Prefix:DR
First Name:MILTON
Middle Name:AMIS
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S INDIANA AVE APT 606
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3225
Mailing Address - Country:US
Mailing Address - Phone:901-299-0014
Mailing Address - Fax:
Practice Address - Street 1:1250 S INDIANA AVE APT 606
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3225
Practice Address - Country:US
Practice Address - Phone:901-299-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-20
Last Update Date:2018-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021141225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist