Provider Demographics
NPI:1689777625
Name:TALLACKSON, DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:TALLACKSON
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:P O B 840853 STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4817
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2549
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5919207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0039ENOtherBLUE CROSS BLUE SHIELD
TX1305062-05Medicaid
TX130506207Medicaid
TX8AG300OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX130506207Medicaid
TXTXB119106Medicare PIN
TX8AG300OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX00389LMedicare PIN