Provider Demographics
NPI:1629050604
Name:DICKINSON, MINDY JANE (OD)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:JANE
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:JANE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4353 DODGE STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2709
Mailing Address - Country:US
Mailing Address - Phone:402-552-2020
Mailing Address - Fax:402-552-2367
Practice Address - Street 1:715 HARMONY STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:402-552-2020
Practice Address - Fax:402-552-2367
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1238152W00000X
IA2321152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0463646Medicaid
NE278982Medicare ID - Type Unspecified
V05522Medicare UPIN
IA0463646Medicaid