Provider Demographics
NPI:1679585004
Name:DICKERSON, ROBERT RAY (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAY
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:STE. 108
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-1547
Mailing Address - Country:US
Mailing Address - Phone:727-456-4250
Mailing Address - Fax:727-346-1044
Practice Address - Street 1:10080 BALAYE RUN DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7902
Practice Address - Country:US
Practice Address - Phone:813-490-6100
Practice Address - Fax:813-490-6105
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52195207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048964600Medicaid
FL07123OtherBCBS
FL295449OtherAVMED
FL07123OtherBCBS
FL295449OtherAVMED