Provider Demographics
NPI:1285667089
Name:RETZ, JACY L (MD)
Entity Type:Individual
Prefix:
First Name:JACY
Middle Name:L
Last Name:RETZ
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:500 W MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4220
Practice Address - Country:US
Practice Address - Phone:615-371-7879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002001742207RP1001X, 207RC0200X
TXN5358207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1285667089OtherBLUE CROSS BLUE SHIELD
TX217643003Medicaid
TX75-2616977-042OtherTRICARE
810000902OtherRR MEDICARE
TX8EB371OtherBCBS BLUE
OK100227160AMedicaid
MO205785108Medicaid
KS100416540AMedicaid
TXP01290935OtherRAIL ROAD
MO144600OtherANTHEM
TX217643001Medicaid
TXP00898407OtherMEDICARE RR
OK100227160AMedicaid
NE$$$$$$$$$Medicaid
TXP00898407OtherMEDICARE RR
OK100227160AMedicaid
E95519Medicare UPIN