Provider Demographics
NPI:1225296676
Name:STICKNEY, DWIGHT RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:RAYMOND
Last Name:STICKNEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5275 ASHBY LN
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9425
Mailing Address - Country:US
Mailing Address - Phone:916-600-5116
Mailing Address - Fax:916-797-1583
Practice Address - Street 1:5275 ASHBY LN
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-9425
Practice Address - Country:US
Practice Address - Phone:916-600-5116
Practice Address - Fax:916-797-1583
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-01
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC370592085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA36467Medicare UPIN