Provider Demographics
NPI:1669497194
Name:DICKSON, DANE J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANE
Middle Name:J
Last Name:DICKSON
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 1:380 WALKER DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1657
Mailing Address - Country:US
Mailing Address - Phone:208-356-9559
Mailing Address - Fax:208-356-6601
Practice Address - Street 1:380 WALKER DRIVE
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-9559
Practice Address - Fax:208-356-6601
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8118207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010032448OtherBLUE SHIELD
ID8J950OtherBLUE CROSS
ID8J950OtherBLUE CROSS
IDG95136Medicare UPIN