Provider Demographics
NPI:1013970680
Name:DIMMICK, GREGG JEFFRY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:JEFFRY
Last Name:DIMMICK
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 1:2100 REGIONAL MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-9719
Mailing Address - Country:US
Mailing Address - Phone:979-532-1700
Mailing Address - Fax:979-532-6793
Practice Address - Street 1:2100 REGIONAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-9719
Practice Address - Country:US
Practice Address - Phone:979-532-1700
Practice Address - Fax:979-532-6793
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0169208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124957507Medicaid
TX820622OtherBC/BS TX #
TX124957502Medicaid
TX8DE526OtherBC/BS #
TX370002795OtherRAILROAD GBA - RAILROAD MEDICARE
TX124957502Medicaid
TXTXB150494Medicare PIN
TX124957507Medicaid