Provider Demographics
NPI:1700919578
Name:DICK, EDWARD LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEWIS
Last Name:DICK
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 1:1406 FITCH ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78211-1406
Mailing Address - Country:US
Mailing Address - Phone:210-922-6922
Mailing Address - Fax:
Practice Address - Street 1:1406 FITCH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78211-1406
Practice Address - Country:US
Practice Address - Phone:210-922-6922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3281207Q00000X, 208000000X
OK18994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics