Provider Demographics
NPI:1679548358
Name:DICKEY, EDGAR GREGG (OD)
Entity type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:GREGG
Last Name:DICKEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837
Mailing Address - Country:US
Mailing Address - Phone:618-842-2655
Mailing Address - Fax:618-842-2656
Practice Address - Street 1:102 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837
Practice Address - Country:US
Practice Address - Phone:618-842-2655
Practice Address - Fax:618-842-2656
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1679548358Medicare NSC
293140Medicare ID - Type Unspecified