Provider Demographics
NPI:1083604458
Name:MEDLOCK, VIRGIL B (MD)
Entity Type:Individual
Prefix:
First Name:VIRGIL
Middle Name:B
Last Name:MEDLOCK
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 650500
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0500
Mailing Address - Country:US
Mailing Address - Phone:214-369-8555
Mailing Address - Fax:214-369-2683
Practice Address - Street 1:3900 JUNIUS ST
Practice Address - Street 2:SUITE 500
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1615
Practice Address - Country:US
Practice Address - Phone:214-823-7090
Practice Address - Fax:214-823-1644
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3615207X00000X, 207XS0106X, 207XS0114X, 207XX0005X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A5019OtherBCBS
TX152255901Medicaid
TX152255902Medicaid
TX152255903Medicaid
TXTXB146868Medicare PIN
TXP01064943Medicare PIN
TXTXB146641Medicare PIN
H21612Medicare UPIN
TX152255903Medicaid
TX152255902Medicaid