Provider Demographics
NPI:1588984264
Name:DICKEY, TISHA N (DO)
Entity type:Individual
Prefix:
First Name:TISHA
Middle Name:N
Last Name:DICKEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORGE VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:MA
Mailing Address - Zip Code:01450-2047
Mailing Address - Country:US
Mailing Address - Phone:978-449-0289
Mailing Address - Fax:
Practice Address - Street 1:1 FORGE VILLAGE RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:MA
Practice Address - Zip Code:01450-2047
Practice Address - Country:US
Practice Address - Phone:978-449-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA262493207Q00000X
DEC20010396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine