Provider Demographics
NPI:1144217084
Name:CORLEY, DAVID DICKSON JR (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DICKSON
Last Name:CORLEY
Suffix:JR
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 1:1300 W TERRELL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2810
Mailing Address - Country:US
Mailing Address - Phone:817-252-5000
Mailing Address - Fax:817-252-5060
Practice Address - Street 1:1300 W TERRELL AVE STE 500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2810
Practice Address - Country:US
Practice Address - Phone:817-252-5000
Practice Address - Fax:817-252-5060
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4251207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1253643-02Medicaid
TX110188988OtherRAIL ROAD MEDICARE
TX85K259OtherBLLUE CROSS
TX125364305Medicaid
TX110188988OtherRAIL ROAD MEDICARE
TXF50326Medicare UPIN
TX1253643-02Medicaid
TX125364305Medicaid