Provider Demographics
NPI:1912210576
Name:MARK E DICKSON MD PA
Entity Type:Organization
Organization Name:MARK E DICKSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-957-0016
Mailing Address - Street 1:3305 N CALAIS ST
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-1796
Mailing Address - Country:US
Mailing Address - Phone:903-957-0016
Mailing Address - Fax:903-957-0038
Practice Address - Street 1:3305 N CALAIS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-1796
Practice Address - Country:US
Practice Address - Phone:903-957-0016
Practice Address - Fax:903-957-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6165208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219531501Medicaid
TX219531501Medicaid