Provider Demographics
NPI:1043446206
Name:DICKERSON, JEREMY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:LEE
Last Name:DICKERSON
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:PO BOX 847824
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7824
Mailing Address - Country:US
Mailing Address - Phone:903-877-7777
Mailing Address - Fax:903-877-5080
Practice Address - Street 1:1139 E SONTERRA BLVD STE 205
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4349
Practice Address - Country:US
Practice Address - Phone:210-874-3359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10035367207Q00000X
TXP4860207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine