Provider Demographics
NPI:1679527006
Name:DRIESSNER, JERRY S (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:S
Last Name:DRIESSNER
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75456-0909
Mailing Address - Country:US
Mailing Address - Phone:903-572-4191
Mailing Address - Fax:
Practice Address - Street 1:2001 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2371
Practice Address - Country:US
Practice Address - Phone:903-577-6186
Practice Address - Fax:903-577-6131
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE08932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX02191095Medicaid
E07908Medicare UPIN
TXC4418Medicare ID - Type Unspecified