Provider Demographics
NPI:1003893942
Name:DICKENS, MICHAEL DOUGLAS (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DOUGLAS
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 1:103 KERRY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-2924
Mailing Address - Country:US
Mailing Address - Phone:434-973-8493
Mailing Address - Fax:
Practice Address - Street 1:1011 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5354
Practice Address - Country:US
Practice Address - Phone:434-296-9161
Practice Address - Fax:434-296-1036
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2012-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023851208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010714OtherCIGNA
VA333839OtherANTHEM
VA42720OtherVETRI
VA12062000003OtherSOUTHERN HEALTH
VA006725791Medicaid
VA267071OtherMAMSI/ALLIANCE
VA010714OtherCIGNA