Provider Demographics
NPI:1457430464
Name:DICKINSON, MARK S (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13190 OWENS WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-7357
Mailing Address - Country:US
Mailing Address - Phone:404-218-4912
Mailing Address - Fax:770-872-7463
Practice Address - Street 1:13190 OWENS WAY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-7357
Practice Address - Country:US
Practice Address - Phone:404-218-4912
Practice Address - Fax:770-872-7463
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000313046BMedicaid
GA000313046AMedicaid
GA000313046AMedicaid
GAGRP6345Medicare PIN