Provider Demographics
NPI:1104827922
Name:DICKINSON, WADE ALDEN (MD)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:ALDEN
Last Name:DICKINSON
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 1:3812 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-4301
Mailing Address - Country:US
Mailing Address - Phone:559-495-3120
Mailing Address - Fax:559-495-3134
Practice Address - Street 1:3152 N MILLBROOK AVE
Practice Address - Street 2:#SUITE B
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1459
Practice Address - Country:US
Practice Address - Phone:559-244-0133
Practice Address - Fax:559-244-0148
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62554207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA62554OtherCAL STATE LIC NUMBER
ARA62554OtherCAL STATE LIC NUMBER