Provider Demographics
NPI:1134681349
Name:DICKERSON DALLAS PAIN ON PA
Entity Type:Organization
Organization Name:DICKERSON DALLAS PAIN ON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JANWAY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:972-850-9179
Mailing Address - Street 1:1675 REPUBLIC PKWY
Mailing Address - Street 2:STE 201
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6902
Mailing Address - Country:US
Mailing Address - Phone:713-355-1500
Mailing Address - Fax:713-629-1945
Practice Address - Street 1:1675 REPUBLIC PKWY STE 201
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6902
Practice Address - Country:US
Practice Address - Phone:972-850-9179
Practice Address - Fax:877-720-5614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-05
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty