1912991795 NPI number — DR. MINDY J DICKERMAN M.D.

Table of content: DR. MINDY J DICKERMAN M.D. (NPI 1912991795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912991795 NPI number — DR. MINDY J DICKERMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERMAN
Provider First Name:
MINDY
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FINK
Provider Other First Name:
MINDY
Provider Other Middle Name:
JILL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1912991795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLAND
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19732-0191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
302-651-4945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 ROCKLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19803-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-651-4200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2005

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: 2080P0203X , with the licence number:  MD437867 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080H0002X , with the licence number: C1-0012274 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036113329 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".