Provider Demographics
NPI:1942195698
Name:DICKSON, IFIOKOBONG DANIEL (MD)
Entity type:Individual
Prefix:
First Name:IFIOKOBONG
Middle Name:DANIEL
Last Name:DICKSON
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 1:1675 LEAHY ST STE 315A
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1150 E SHERMAN BLVD STE 1100
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-4607
Practice Address - Country:US
Practice Address - Phone:231-672-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351055191207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine