Provider Demographics
NPI:1134108715
Name:DICKSON, MARK EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:DICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:EDWARD
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA
Mailing Address - Street 1:3305 N CALAIS ST
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-3110
Mailing Address - Country:US
Mailing Address - Phone:903-957-0016
Mailing Address - Fax:903-957-0038
Practice Address - Street 1:3305 N CALAIS ST
Practice Address - Street 2:SUITE # 100
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-3110
Practice Address - Country:US
Practice Address - Phone:903-957-0016
Practice Address - Fax:903-957-0038
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6165208600000X
OK19378208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100153640AMedicaid
TX034452501Medicaid
TX034452501Medicaid
TXTXB107316Medicare UPIN
OK247632402Medicare UPIN
TXF8125Medicare UPIN