Healthcare Provider Details

I. General information

NPI: 1528021706
Provider Name (Legal Business Name): MATTHEW JORDAN DICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 HUDSON AVENUE ADIRONDACK ENT
GLENS FALLS NY
12801-4363
US

IV. Provider business mailing address

100 PARK STREET GLENS FALLS HOSPITAL - CREDENTIALING
GLENS FALLS NY
12801-4413
US

V. Phone/Fax

Practice location:
  • Phone: 518-926-1380
  • Fax: 518-926-1385
Mailing address:
  • Phone: 518-926-5924
  • Fax: 518-926-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number244280
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number57061
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: