Provider Demographics
NPI:1831173673
Name:DICKENS, ROBERT A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:DICKENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-0125
Mailing Address - Country:US
Mailing Address - Phone:920-684-8101
Mailing Address - Fax:920-684-1224
Practice Address - Street 1:4555 W SCHROEDER DR
Practice Address - Street 2:SUITE 170
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-1475
Practice Address - Country:US
Practice Address - Phone:414-365-3210
Practice Address - Fax:414-365-3225
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302850202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31523800Medicaid
B75820Medicare UPIN
WI31523800Medicaid
WI000038134Medicare PIN