Provider Demographics
NPI:1376591354
Name:DICKINSON, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
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 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 100 BLDG B
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-1268
Practice Address - Fax:801-812-5454
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1660021205207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT100002620OtherPALMETTO GBA
UT29-00040OtherUNITED HEALTHCARE
UT107006219101OtherIHC HEALTHPLANS
UT0049OtherDMBA
UTQM0000009178OtherALTIUS
UT5285OtherPEHP
UTQM0000009178OtherALTIUS
UT107006219101OtherIHC HEALTHPLANS
UT000001341Medicare ID - Type UnspecifiedMEDICARE
UT870281028000Medicaid