Provider Demographics
NPI:1326118183
Name:DICKEY, MARK RAYNER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAYNER
Last Name:DICKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4405 GUADALUPE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-3616
Mailing Address - Country:US
Mailing Address - Phone:512-452-3000
Mailing Address - Fax:512-452-3004
Practice Address - Street 1:4405 GUADALUPE ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-3616
Practice Address - Country:US
Practice Address - Phone:512-452-3000
Practice Address - Fax:512-452-3004
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM4034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH66408Medicare UPIN