Healthcare Provider Details

I. General information

NPI: 1124210224
Provider Name (Legal Business Name): RICHARD L DICKSON, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 WEST E. ST.
FORKS WA
98331-1918
US

IV. Provider business mailing address

PO BOX 1918
FORKS WA
98331-1918
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-6642
  • Fax: 360-374-5335
Mailing address:
  • Phone: 360-374-6642
  • Fax: 360-374-5335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number600372068
License Number StateWA

VIII. Authorized Official

Name: MR. RICHARD LEE DICKSON
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 360-374-6642