Provider Demographics
NPI:1407831357
Name:SACKRISON, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:SACKRISON
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 1:2821 E. PRESIDENT GEORGE BUSH FREEWAY
Mailing Address - Street 2:SUITE 404
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4266
Mailing Address - Country:US
Mailing Address - Phone:214-576-2227
Mailing Address - Fax:214-576-2229
Practice Address - Street 1:2821 E PRESIDENT GEORGE BUSH FREEWAY
Practice Address - Street 2:SUITE 404
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4266
Practice Address - Country:US
Practice Address - Phone:214-576-2227
Practice Address - Fax:214-576-2229
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104576703Medicaid
TX8L19156Medicare PIN
TX104576703Medicaid