Basic Information
| Provider Information | |||||||||
| NPI: | 1932526860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKEY | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD, MPH | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DICKEY | ||||||||
| OtherFirstName: | BENJAMIN | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2323 BETHARDS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954058500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7149376233 | ||||||||
| Practice Location | |||||||||
| Address1: | 2323 BETHARDS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954058500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075421611 | ||||||||
| FaxNumber: | 7075429958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | A149307 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.