Provider Demographics
NPI:1568694586
Name:WILCOX, DARRELL WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:WALLACE
Last Name:WILCOX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-5000
Practice Address - Street 1:9250 PINECROFT DR
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-3218
Practice Address - Country:US
Practice Address - Phone:281-364-5805
Practice Address - Fax:281-364-5875
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10035402-ID#540187390200000X
TXP3485207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX324224002Medicaid
TX324224001Medicaid
TX8DY159OtherBLUE CROSS BLUE SHIELD
TXP01237859OtherRAILROAD MEDICARE
TX308145YK6UMedicare PIN