Provider Demographics
NPI:1972655652
Name:ODERO, DICKSON O (MD)
Entity Type:Individual
Prefix:DR
First Name:DICKSON
Middle Name:O
Last Name:ODERO
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 153701
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75915-3701
Mailing Address - Country:US
Mailing Address - Phone:936-632-4282
Mailing Address - Fax:
Practice Address - Street 1:10 MEDICAL CENTER BLVD
Practice Address - Street 2:A
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3173
Practice Address - Country:US
Practice Address - Phone:936-632-4282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3265207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
742080151759040000OtherTRI CARE
TX00ET90OtherBLUE CROSS BLUE SHIELD
TX114579901Medicaid
TX00ET90Medicare ID - Type Unspecified
TX00ET90OtherBLUE CROSS BLUE SHIELD
TX114579901Medicaid