Provider Demographics
NPI:1700983350
Name:DICKSON, HEATHER ANNATOYN (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:ANNATOYN
Last Name:DICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15621 WINDMILL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1858
Mailing Address - Country:US
Mailing Address - Phone:313-822-5427
Mailing Address - Fax:
Practice Address - Street 1:114 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3619
Practice Address - Country:US
Practice Address - Phone:313-886-4060
Practice Address - Fax:313-886-4043
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1015901080Medicaid
MI11274951OtherCAQH PROVIDER ID
MID72693Medicare UPIN