Healthcare Provider Details

I. General information

NPI: 1205837408
Provider Name (Legal Business Name): MARC E DICKLIN P.A. -C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LANGWORTHY ST
DUBUQUE IA
52001-7313
US

IV. Provider business mailing address

1500 ASSOCIATES DR
DUBUQUE IA
52002-2201
US

V. Phone/Fax

Practice location:
  • Phone: 563-584-3455
  • Fax: 563-584-3314
Mailing address:
  • Phone: 563-584-4100
  • Fax: 563-584-4110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001351
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: