Provider Demographics
NPI:1326007816
Name:DEKERATRY, DOMINIC R (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:R
Last Name:DEKERATRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678698
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8698
Mailing Address - Country:US
Mailing Address - Phone:512-637-2002
Mailing Address - Fax:512-637-2007
Practice Address - Street 1:1900 SCENIC DRIVE
Practice Address - Street 2:SUITE 2208
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626
Practice Address - Country:US
Practice Address - Phone:512-819-0132
Practice Address - Fax:512-819-9335
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0787207RC0200X, 207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1436107-03Medicaid
TX1436107-03Medicaid
TXG21472Medicare UPIN