Healthcare Provider Details

I. General information

NPI: 1285845040
Provider Name (Legal Business Name): JEFFREY DOUGLAS DICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

1801 CHAMPLIN DR APT 1208
LITTLE ROCK AR
72223-3980
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-6337
  • Fax:
Mailing address:
  • Phone: 501-821-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number390200000X
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101242576
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: