Provider Demographics
NPI:1154320059
Name:DICKINSON, MARK WADE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WADE
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 1:388 COMMONWEALTH AVE
Mailing Address - Street 2:MGH BACK BAY
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-2800
Mailing Address - Country:US
Mailing Address - Phone:617-267-7171
Mailing Address - Fax:617-262-2608
Practice Address - Street 1:388 COMMONWEALTH AVE
Practice Address - Street 2:MGH BACK BAY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-2800
Practice Address - Country:US
Practice Address - Phone:617-267-7171
Practice Address - Fax:617-262-2608
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230380207R00000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA77715OtherHPHC
MAAA77715OtherMASSHEALTH
MA121680OtherFALLON
MA2128071Medicaid
MAOX2506OtherMEDICARE PTAN GROUP 21240
MA3975642OtherCIGNA
MA495561OtherTUFTS
MA5035676OtherAETNA
MA96009801OtherNETWORK HEALTH
MAJ41145OtherBCBS
MAOX2507OtherMEDICARE PTAN GROUP 21241
MAAA77715OtherMASSHEALTH
A41092Medicare PIN