Provider Demographics
NPI:1164607446
Name:DVORAK, DERRICK WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:WILLIAM
Last Name:DVORAK
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 1:4835 LBJ FWY STE 900
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-6001
Mailing Address - Country:US
Mailing Address - Phone:469-420-5527
Mailing Address - Fax:
Practice Address - Street 1:6800 SCENIC DR
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4552
Practice Address - Country:US
Practice Address - Phone:972-520-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7526207P00000X
IN01068417A207Q00000X
TXP3527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200986660Medicaid
IN000000666689OtherANTHEM BCBS
SD5613203Medicaid
SD5884Medicare PIN
IN200986660Medicaid