Provider Demographics
NPI:1184665697
Name:DICKERSON, CRYSTAL DAWNELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:DAWNELLE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:DAWNELLE
Other - Last Name:POWELL; ASKEW; BONINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 911322
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1322
Mailing Address - Country:US
Mailing Address - Phone:888-269-7001
Mailing Address - Fax:303-764-6640
Practice Address - Street 1:721 S AUBURN ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-5629
Practice Address - Country:US
Practice Address - Phone:509-547-2204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0035551207Q00000X
WA60959396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO73936006Medicaid
COC439248Medicare PIN
CO73936006Medicaid