Provider Demographics
NPI:1366893752
Name:DICKINSON, KIRSTEN (MD)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:
Other - Last Name:GOETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:12327 STRATFORD DR
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8148
Practice Address - Country:US
Practice Address - Phone:515-224-7088
Practice Address - Fax:515-224-9228
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301504690207ND0101X, 207N00000X
OH35.139357207N00000X
IAR-10964207N00000X
IAR10695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine