1083834428 NPI number — DONALD G. DICKEN, MD, PC

Table of content: (NPI 1083834428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083834428 NPI number — DONALD G. DICKEN, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DONALD G. DICKEN, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1083834428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N. 14TH AVE
Provider Second Line Business Mailing Address:
SUITE 275
Provider Business Mailing Address City Name:
PASCO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99301-4079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-545-0414
Provider Business Mailing Address Fax Number:
509-545-9398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 N. 14TH AVE
Provider Second Line Business Practice Location Address:
SUITE 275
Provider Business Practice Location Address City Name:
PASCO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99301-4079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-545-0414
Provider Business Practice Location Address Fax Number:
509-545-9398
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOREHOUSE
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
509-545-0414

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD00028507 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1110584 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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