Healthcare Provider Details

I. General information

NPI: 1366893752
Provider Name (Legal Business Name): KIRSTEN DICKINSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIRSTEN GOETZ MD

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12327 STRATFORD DR
CLIVE IA
50325-8148
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 515-224-7088
  • Fax: 515-224-9228
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number4301504690
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35.139357
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberR-10964
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR10695
License Number StateIA
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301504690
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: