Provider Demographics
NPI:1003904962
Name:PICKETT, JAMES DWAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DWAYNE
Last Name:PICKETT
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 1:508 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2808
Mailing Address - Country:US
Mailing Address - Phone:936-760-4600
Mailing Address - Fax:936-760-4601
Practice Address - Street 1:508 MEDICAL CENTER BLVD
Practice Address - Street 2:STE 200
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:936-760-4600
Practice Address - Fax:936-760-4601
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7053207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123004705Medicaid
TX123004705Medicaid
TX8600N3Medicare PIN
GA60067550Medicare PIN