Provider Demographics
NPI:1790720605
Name:DACKIW, ALAN PB (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:PB
Last Name:DACKIW
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-2900
Mailing Address - Fax:214-645-8161
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-2900
Practice Address - Fax:214-645-8161
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61153208600000X
TXK6557208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404012100Medicaid
MD404012100Medicaid
MDG80543Medicare UPIN