Provider Demographics
NPI:1013936814
Name:DICK, MICHAEL PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PHILIP
Last Name:DICK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:260-458-5831
Practice Address - Street 1:3898 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-425-5750
Practice Address - Fax:260-425-5755
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-05-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN010419052080P0208X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2024786Medicaid
IN100460690Medicaid
OH2024786Medicaid
IN100460690Medicaid