Provider Demographics
NPI:1326040643
Name:DICKSON, RICHARD WARREN (DO)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WARREN
Last Name:DICKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:155 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-2164
Practice Address - Fax:910-715-1247
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO 1355207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5845483Medicaid
TN3306187Medicaid
0281780003Medicare PIN
TN3306187Medicare ID - Type Unspecified
0281780001Medicare PIN
TN3700592Medicare UPIN
VA5845483Medicaid
TN3306187Medicaid
TN103I086169Medicare UPIN
TN110205140Medicare PIN
TNCA5023Medicare PIN