Provider Demographics
NPI:1194717355
Name:DICKSON, KRISTI S (MD)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:S
Last Name:DICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8326 NAAB RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1920
Mailing Address - Country:US
Mailing Address - Phone:317-871-0000
Mailing Address - Fax:317-871-0010
Practice Address - Street 1:8326 NAAB RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1920
Practice Address - Country:US
Practice Address - Phone:317-871-0000
Practice Address - Fax:317-871-0010
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058422A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00174999OtherMEDICARE RAILROAD #
IN200311740FMedicaid
IN320299OtherANTHEM PIN#
IN4675512OtherAETNA PIN#
IN200138140Medicaid
IN200138140Medicaid
205110YMedicare Oscar/Certification