MEDICARE: DR. MATTHEW DOUGLAS DICKSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	4064	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457388720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW DOUGLAS DICKSON D.O.

Provider Business Mailing Address
First Line	:	PO BOX 660969
Second Line	:
City	:	ARCADIA
State	:	CA
Zip	:	91066-0969
Country	:	US
Telephone Number	:	626-447-0296
Fax Number	:	626-447-6057

Provider Business Practice Location Address
First Line	:	1628 PALM AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-1027
Country	:	US
Telephone Number	:	619-591-9999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	11/20/2018

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