Provider Demographics
NPI:1942287735
Name:DICKINSON, BRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:
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:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:515 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1919
Practice Address - Country:US
Practice Address - Phone:573-760-7920
Practice Address - Fax:573-756-9597
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004030203207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207380403Medicaid
MO934843210Medicare PIN
MO934843211Medicare PIN
MO207380403Medicaid
MO934841369Medicare PIN