Provider Demographics
NPI:1336155118
Name:DICKINSON, GAIL LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:LOUISE
Last Name:DICKINSON
Suffix:
Gender:F
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 366
Mailing Address - Street 2:
Mailing Address - City:S WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06267-0366
Mailing Address - Country:US
Mailing Address - Phone:860-928-7775
Mailing Address - Fax:860-928-1397
Practice Address - Street 1:168 RTE. 171
Practice Address - Street 2:
Practice Address - City:S WOODSTOCK
Practice Address - State:CT
Practice Address - Zip Code:06267-0366
Practice Address - Country:US
Practice Address - Phone:860-928-7775
Practice Address - Fax:860-928-1397
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032613207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1326132Medicaid
CT30169OtherHEALTHNET
CT010032613CT01OtherANTHEM BCBS
CTF37770Medicare UPIN
CT110004601Medicare ID - Type Unspecified
CTD400002849Medicare PIN