Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YS0123X | Facial Plastic Surgeon | 57061 | GA |
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 244280 | NY |
NPI | 1528021706 |
---|---|
Provider Name | Dr. Matthew Jordan Dickson |
First Address | Glens Falls, NY 12801-4413 |
Second Address | Glens Falls, NY 12801-4363 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2006 |
Last Update Date | 02/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02897047 | (05) | NY |
156954 | (02) |