Provider Demographics
NPI:1629056908
Name:PATRICK, TODD A (MD PHD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:PATRICK
Suffix:
Gender:M
Credentials:MD PHD
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST
Practice Address - Street 2:STE 330
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8369
Practice Address - Country:US
Practice Address - Phone:903-525-7995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44797207T00000X
TXN1052207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN689448800Medicaid
TX8BC076OtherBCBS OF TEXAS
TX8BC076OtherBCBS OF TEXAS
MN140000257Medicare ID - Type Unspecified
TX8L2009Medicare Oscar/Certification
MN689448800Medicaid