Provider Demographics
NPI:1922158500
Name:TRICKETT, CORY V (DO)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:V
Last Name:TRICKETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:MCHE-QD(CREDS)
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3183 W STATE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1712
Practice Address - Country:US
Practice Address - Phone:423-764-7131
Practice Address - Fax:423-245-3136
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73663207ND0101X
ND10791207ND0101X
TN3466207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery