Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | F4805 | TX |
NPI | 1245203488 |
---|---|
Provider Name | Jerry Dickey |
First Address | Fort Worth, TX 76199-0335 |
Second Address | Fort Worth, TX 76107-2553 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2006 |
Last Update Date | 05/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
044103201 | (05) | TX |
120001842 | RAILROAD MEDICARE (01) | TX |
859571 | BCBS (01) | TX |
E25424 | (02) | TX |