Provider Demographics
NPI:1356475131
Name:DICKENS, WINBURN JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:WINBURN
Middle Name:JACKSON
Last Name:DICKENS
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 1:152 MONROE HIGHWAY
Mailing Address - Street 2:P.O. BOX 664
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-0664
Mailing Address - Country:US
Mailing Address - Phone:770-868-0325
Mailing Address - Fax:
Practice Address - Street 1:152 MONROE HWY
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-0664
Practice Address - Country:US
Practice Address - Phone:770-868-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0139652085R0001X
FLME 372092085R0001X
TN405762085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology