Provider Demographics
NPI:1326139270
Name:DICKSON, CHERYL (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 OAKLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008
Mailing Address - Country:US
Mailing Address - Phone:269-337-4507
Mailing Address - Fax:
Practice Address - Street 1:1000 OAKLAND DRIVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008
Practice Address - Country:US
Practice Address - Phone:269-337-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03976200207PP0204X, 208000000X
NJMA39762208000000X
MI4301104278208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2059002Medicaid
NJD20060Medicare UPIN
NJ655245Medicare PIN
NJ2059002Medicaid