Provider Demographics
NPI:1356527683
Name:DICKERSON, VIVIAN M (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:M
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1 HOAG DR
Mailing Address - Street 2:PO BOX 6100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4162
Mailing Address - Country:US
Mailing Address - Phone:949-764-5414
Mailing Address - Fax:949-764-8339
Practice Address - Street 1:1 HOAG DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-764-5414
Practice Address - Fax:949-764-8339
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG049834207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology