1467743963 NPI number — DR. TIMOTHY JOSEPH DICKSON MD

Table of content: DR. TIMOTHY JOSEPH DICKSON MD (NPI 1467743963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467743963 NPI number — DR. TIMOTHY JOSEPH DICKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKSON
Provider First Name:
TIMOTHY
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1467743963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
291 LINDSAY ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINNIPEG
Provider Business Mailing Address State Name:
MANITOBA
Provider Business Mailing Address Postal Code:
R3N1H2
Provider Business Mailing Address Country Code:
CA
Provider Business Mailing Address Telephone Number:
204-990-6204
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
622 W 168TH ST PH 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10032-3720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-305-5232
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2011

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: 390200000X , with the licence number:  16-653 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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