Healthcare Provider Details

I. General information

NPI: 1477582872
Provider Name (Legal Business Name): JOHN T DICKINSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 RIVERBEND DR STE 300
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

3355 RIVERBEND DR STE 300
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-9303
  • Fax: 541-868-9306
Mailing address:
  • Phone: 541-868-9303
  • Fax: 541-868-9306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD8731
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: