Provider Demographics
NPI:1154825974
Name:DICKERSON, TAYLOR GRIFFIN (MD)
Entity Type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:GRIFFIN
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 DOMINION PLZ
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1013
Mailing Address - Country:US
Mailing Address - Phone:903-534-6200
Mailing Address - Fax:903-939-0755
Practice Address - Street 1:1367 DOMINION PLZ
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-534-6200
Practice Address - Fax:903-939-0755
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT7197207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program