Provider Demographics
NPI:1407026487
Name:DICKSTEIN, RIAN JASON (MD)
Entity Type:Individual
Prefix:
First Name:RIAN
Middle Name:JASON
Last Name:DICKSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5421
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:
Practice Address - Street 1:7580 BUCKINGHAM BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:HANOVER
Practice Address - State:MD
Practice Address - Zip Code:21076-3181
Practice Address - Country:US
Practice Address - Phone:410-760-9400
Practice Address - Fax:410-787-1911
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5652208800000X
MDD073974208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD310803100Medicaid
MD310803100Medicaid
TXTXB127096Medicare PIN
TX8CW230OtherBCBS
MD310803100Medicaid