Provider Demographics
NPI:1760455075
Name:DICKSON, RICHARD LEE (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LEE
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:PO BOX 1918
Mailing Address - Street 2:481 W E ST
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331
Mailing Address - Country:US
Mailing Address - Phone:360-374-6642
Mailing Address - Fax:360-374-5335
Practice Address - Street 1:481 W E ST
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331
Practice Address - Country:US
Practice Address - Phone:360-374-6642
Practice Address - Fax:360-374-5335
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA16829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1641208Medicaid
WA1641208Medicaid
A14710Medicare UPIN