Provider Demographics
NPI:1467656025
Name:DICKERSON, SAMUEL WENDELL (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:WENDELL
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DO
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 SCOTT AND WHITE DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6441
Practice Address - Country:US
Practice Address - Phone:979-207-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0022044207L00000X
TXM9971207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2790064977OtherMYUTMB 2790064977-COMMERCIAL NUMBER
2790064977OtherMYUTMB 2790064977-COMMERCIAL NUMBER