Provider Demographics
NPI:1093763633
Name:DICKIE, MARK HANSEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HANSEN
Last Name:DICKIE
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 1:214 HALBERT LN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-5455
Mailing Address - Country:US
Mailing Address - Phone:254-223-1154
Mailing Address - Fax:
Practice Address - Street 1:214 HALBERT LN
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-5455
Practice Address - Country:US
Practice Address - Phone:254-223-1154
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine