Provider Demographics
NPI:1770670259
Name:DICKENS, CATHERINE K (MD)
Entity type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:K
Last Name:DICKENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 AZALIA DR
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4908
Mailing Address - Country:US
Mailing Address - Phone:912-681-3040
Mailing Address - Fax:912-681-3040
Practice Address - Street 1:107 CANAL ST
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4016
Practice Address - Country:US
Practice Address - Phone:912-355-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00553407EMedicaid
GAF63425Medicare UPIN
GA00553407EMedicaid