Provider Demographics
NPI:1043605280
Name:PICKETT, CASEY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:ROBERT
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 1:149 HART ST BLDG 1200
Mailing Address - Street 2:
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311-3430
Mailing Address - Country:US
Mailing Address - Phone:940-676-2273
Mailing Address - Fax:940-676-3484
Practice Address - Street 1:149 HART ST BLDG 1200
Practice Address - Street 2:
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3430
Practice Address - Country:US
Practice Address - Phone:940-676-2273
Practice Address - Fax:940-676-3484
Is Sole Proprietor?:No
Enumeration Date:2015-04-04
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD463737208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program