Provider Demographics
NPI:1437111614
Name:NYSTROM, GERALD (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:NYSTROM
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 1:3001 E PRESIDENT GEORGE BUSH HWY STE 225
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3569
Mailing Address - Country:US
Mailing Address - Phone:214-343-6663
Mailing Address - Fax:214-343-2814
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:214-343-6663
Practice Address - Fax:214-343-2814
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK61942080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK6194OtherLICENSE
TX040275201Medicaid