Provider Demographics
NPI:1669664744
Name:DICKSON MICHELSON, ELIZABETH LOUISE (M D)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LOUISE
Last Name:DICKSON MICHELSON
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:LOUISE
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M D
Mailing Address - Street 1:8901 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:424-328-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63396207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100016638Medicaid