Provider Demographics
NPI:1780679936
Name:DICKINSON, DANIEL JACKSON (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACKSON
Last Name:DICKINSON
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 1:5320 PROVIDENCE RD STE 301
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4122
Mailing Address - Country:US
Mailing Address - Phone:757-413-7600
Mailing Address - Fax:
Practice Address - Street 1:5320 PROVIDENCE RD STE 301
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4122
Practice Address - Country:US
Practice Address - Phone:757-413-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048745207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005860521Medicaid
VA110008115Medicare ID - Type Unspecified
VA005860521Medicaid