Provider Demographics
NPI:1265642250
Name:KM DICKSON MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KM DICKSON MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-997-4502
Mailing Address - Street 1:1008 OCEAN LN
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2556
Mailing Address - Country:US
Mailing Address - Phone:619-591-9999
Mailing Address - Fax:
Practice Address - Street 1:555 SATURN BLVD STE B292
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-4766
Practice Address - Country:US
Practice Address - Phone:619-591-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty