Provider Demographics
NPI:1215914239
Name:DICKINSON, MARK THOMAS (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 CHARLOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-4035
Mailing Address - Country:US
Mailing Address - Phone:615-250-9200
Mailing Address - Fax:615-250-9251
Practice Address - Street 1:4601 CAROTHERS PKWY
Practice Address - Street 2:STE 475
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-5980
Practice Address - Country:US
Practice Address - Phone:615-790-1660
Practice Address - Fax:615-790-3705
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD37792208800000X
CAA67587208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3886483Medicaid
TNP00035782OtherRR MEDICARE
KY64069941Medicaid
TN4067530OtherBLUE CROSS
TN4067530OtherBLUE CROSS
H86735Medicare UPIN