Provider Demographics
NPI:1104860519
Name:DICKINSON, DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:DICKINSON
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:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95518-1127
Mailing Address - Country:US
Mailing Address - Phone:707-599-1561
Mailing Address - Fax:707-825-1116
Practice Address - Street 1:4058 D ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-6025
Practice Address - Country:US
Practice Address - Phone:707-599-1561
Practice Address - Fax:707-825-1116
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69727207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G697270Medicaid
CA00G697272Medicare ID - Type Unspecified
CAF22698Medicare UPIN