1083669592 NPI number — DR. LAWRENCE DAVID DICKINSON MD

Table of content: DR. LAWRENCE DAVID DICKINSON MD (NPI 1083669592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083669592 NPI number — DR. LAWRENCE DAVID DICKINSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKINSON
Provider First Name:
LAWRENCE
Provider Middle Name:
DAVID
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:
1083669592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1320 EL CAPITAN DR
Provider Second Line Business Mailing Address:
# 300
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94526-6258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-886-3138
Provider Business Mailing Address Fax Number:
510-373-1616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20055 LAKE CHABOT RD
Provider Second Line Business Practice Location Address:
# 110
Provider Business Practice Location Address City Name:
CASTRO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-886-3138
Provider Business Practice Location Address Fax Number:
510-373-1616
Provider Enumeration Date:
05/23/2006

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: 207T00000X , with the licence number:  G84805 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207T00000X , with the licence number: DR.0054873 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 75639700 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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