Provider Demographics
NPI:1649334236
Name:DICKEN, DONALD GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:GEORGE
Last Name:DICKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NORTH 14TH AVENUE
Mailing Address - Street 2:SUITE 275
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-4079
Mailing Address - Country:US
Mailing Address - Phone:509-545-0414
Mailing Address - Fax:509-545-9398
Practice Address - Street 1:1200 NORTH 14TH AVENUE
Practice Address - Street 2:SUITE 275
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-4079
Practice Address - Country:US
Practice Address - Phone:509-545-0414
Practice Address - Fax:509-545-9398
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028507174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1110584Medicaid
WA56275OtherLABOR & IND
WA1110584Medicaid
AB14543Medicare ID - Type Unspecified