Healthcare Provider Details

I. General information

NPI: 1669881470
Provider Name (Legal Business Name): MIRIAM A. DICKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIRIAM A DICKSON MD

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 PARK LAKE DR
PONTE VEDRA FL
32081-0869
US

IV. Provider business mailing address

601 PARK LAKE DR
PONTE VEDRA FL
32081-0869
US

V. Phone/Fax

Practice location:
  • Phone: 305-336-6406
  • Fax: 904-593-9456
Mailing address:
  • Phone: 305-336-6406
  • Fax: 904-593-9456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME135925
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: