Provider Demographics
NPI:1003817206
Name:DICKSON, JOAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:
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 1:310.5 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1945
Mailing Address - Country:US
Mailing Address - Phone:406-377-1179
Mailing Address - Fax:406-377-1199
Practice Address - Street 1:100.5 S. MERRILL AVE.
Practice Address - Street 2:SUITE #24
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-2053
Practice Address - Country:US
Practice Address - Phone:406-377-1179
Practice Address - Fax:406-377-1199
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9958207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT9958OtherSTATE LICENSE
MTH 64257Medicare UPIN