Provider Demographics
NPI:1003898321
Name:DICK, CARROLL DAVID (OD)
Entity Type:Individual
Prefix:
First Name:CARROLL
Middle Name:DAVID
Last Name:DICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 W HWY 82
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240
Mailing Address - Country:US
Mailing Address - Phone:940-665-9111
Mailing Address - Fax:940-665-2508
Practice Address - Street 1:818 W HWY 82
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240
Practice Address - Country:US
Practice Address - Phone:940-665-9111
Practice Address - Fax:940-665-9111
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06706TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214483401Medicaid
TXTXB103475Medicare PIN