Provider Demographics
NPI:1255314423
Name:DICKINSON, TIMOTHY DALE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DALE
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 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:SUITE 258
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5401
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38335207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
10902391OtherCAQH
611077369OtherTAX ID
7580059OtherAETNA
000000311761OtherANTHEM BLUE SHIELD
IN200282600Medicaid
OH0310694Medicaid
KY64074628Medicaid
IN200282600Medicaid
10902391OtherCAQH