Basic Information
| Provider Information | |||||||||
| NPI: | 1366893752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKINSON | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOETZ | ||||||||
| OtherFirstName: | KIRSTEN | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 COOLIDGE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488236381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172033000 | ||||||||
| FaxNumber: | 5172033003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2016 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 35.139357 | OH | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | R-10964 | IA | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | 4301504690 | MI | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207R00000X | R10695 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207N00000X | 4301504690 | MI | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.