Provider Demographics
NPI:1245235092
Name:PAYNE, RICHARD JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JACKSON
Last Name:PAYNE
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 1:2602 SAINT MICHAEL DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2387
Mailing Address - Country:US
Mailing Address - Phone:903-614-5258
Mailing Address - Fax:903-614-5260
Practice Address - Street 1:2602 SAINT MICHAEL DR
Practice Address - Street 2:SUITE 301
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2387
Practice Address - Country:US
Practice Address - Phone:903-614-5258
Practice Address - Fax:903-614-5260
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1617174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82Z085Medicare PIN