Basic Information
| Provider Information | |||||||||
| NPI: | 1700014198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | MEERA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.P.H. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHRESTHA | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | MEERA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D., M.P.H. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 810 WH SMITH BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278343763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527572663 | ||||||||
| FaxNumber: | 4346545574 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 WH SMITH BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278343763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527572663 | ||||||||
| FaxNumber: | 4346545574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0101262902 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MT195182 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 2022-01895 | NC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | 0101262902 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0004X | 2022-01895 | NC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
No ID Information.