Provider Demographics
NPI:1073598199
Name:DAILEY, JIMMY W (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:W
Last Name:DAILEY
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 788
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103-0788
Mailing Address - Country:US
Mailing Address - Phone:903-567-1910
Mailing Address - Fax:903-567-1940
Practice Address - Street 1:1108 S BUFFALO ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-2304
Practice Address - Country:US
Practice Address - Phone:903-567-1910
Practice Address - Fax:903-567-1940
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111854905Medicaid
TX111854905Medicaid