Basic Information
| Provider Information | |||||||||
| NPI: | 1649560731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | ELLIOT | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A143231 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 59963 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 646456 | 01 | CO | MEDICARE | OTHER | KA3249107 | 01 | KS | MEDICARE | OTHER | NA1215131 | 01 | NE | MEDICARE | OTHER | 646435 | 01 | CO | MEDICARE | OTHER | 646579 | 01 | CO | MEDICARE | OTHER | 111257116 | 01 | KS | MEDICARE | OTHER | 646400 | 01 | CO | MEDICARE | OTHER | 201195600A | 05 | KS | MEDICAID | NA1214130 | 01 | NE | MEDICARE | OTHER | 9000159280 | 05 | CO | MEDICAID | NA2517108 | 01 | NE | MEDICARE | OTHER | 646349 | 01 | CO | MEDICARE | OTHER | 646494 | 01 | CO | MEDICARE | OTHER |