Provider Demographics
NPI:1801808530
Name:DICKEY, RAYMOND P (OD)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:P
Last Name:DICKEY
Suffix:
Gender:M
Credentials:OD
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 185
Mailing Address - Street 2:420 N VIRGINIA
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-0185
Mailing Address - Country:US
Mailing Address - Phone:361-552-3445
Mailing Address - Fax:361-552-5483
Practice Address - Street 1:420 N VIRGINIA
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-0185
Practice Address - Country:US
Practice Address - Phone:361-552-3445
Practice Address - Fax:361-552-5483
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03335TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093219602Medicaid
781242OtherHIGHMARK BCBS CLARITY VIS
TX0918570001Medicare NSC
TX00E39CMedicare PIN
781242OtherHIGHMARK BCBS CLARITY VIS