Provider Demographics
NPI:1255594867
Name:ALBERT M. DICKSON MD
Entity type:Organization
Organization Name:ALBERT M. DICKSON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-460-5959
Mailing Address - Street 1:1020 INDEPENDENCE BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5500
Mailing Address - Country:US
Mailing Address - Phone:757-460-5959
Mailing Address - Fax:757-460-9873
Practice Address - Street 1:1020 INDEPENDENCE BLVD
Practice Address - Street 2:STE 104
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5500
Practice Address - Country:US
Practice Address - Phone:757-460-5959
Practice Address - Fax:757-460-9873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101014144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
31203OtherOPTIMA
VA005605440Medicaid
011897313OtherMEDICARE
VA033677OtherBCBS
31203OtherOPTIMA