1245187889 NPI number — TIMOTHY DICKERSON II

Table of content: TIMOTHY DICKERSON II (NPI 1245187889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245187889 NPI number — TIMOTHY DICKERSON II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON
Provider First Name:
TIMOTHY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245187889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 INTERNATIONAL PKWY STE 200, LAKE MARY, FL 32746
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-610-0580
Provider Business Mailing Address Fax Number:
866-611-1558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12911 N TELECOM PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE TERRACE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33637-0907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-553-7880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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