Provider Demographics
NPI:1003800079
Name:GROSSNICKLE, RICHARD DEAN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DEAN
Last Name:GROSSNICKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 NE LOOP 286
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-3444
Mailing Address - Country:US
Mailing Address - Phone:906-785-0083
Mailing Address - Fax:903-785-2947
Practice Address - Street 1:2615 NE LOOP 286
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-3444
Practice Address - Country:US
Practice Address - Phone:906-785-0083
Practice Address - Fax:903-785-2947
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6388207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110097602Medicaid
TX00SC11OtherBLUE CROSS BLUE SHIELD TX
TX110097602Medicaid
TX00SC11OtherBLUE CROSS BLUE SHIELD TX