Provider Demographics
NPI:1720058092
Name:DICKENS, DAVID S (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:DICKENS
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-3595
Mailing Address - Fax:319-356-7659
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:319-356-3595
Practice Address - Fax:319-356-7659
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-45793208000000X, 2080P0207X
MI43010794562080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4395466Medicaid
MI3504111911OtherBCBSM
MID16256022Medicare ID - Type UnspecifiedGROUP #
MI3504111911OtherBCBSM