MEDICARE: MIRIAM A. DICKSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	ME135925	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669881470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM A. DICKSON M.D.

Provider Business Mailing Address
First Line	:	601 PARK LAKE DR
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-0869
Country	:	US
Telephone Number	:	305-336-6406
Fax Number	:	904-593-9456

Provider Business Practice Location Address
First Line	:	601 PARK LAKE DR
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-0869
Country	:	US
Telephone Number	:	305-336-6406
Fax Number	:	904-593-9456

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2014
Last Update Date	:	05/08/2026

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