Provider Demographics
NPI:1912964107
Name:DICKERSON, SANDRA DEE (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DEE
Last Name:DICKERSON
Suffix:
Gender:F
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 224702
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75222-4702
Mailing Address - Country:US
Mailing Address - Phone:972-579-5222
Mailing Address - Fax:972-579-3900
Practice Address - Street 1:400 W INTERSTATE HWY 635 STE 130
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3700
Practice Address - Country:US
Practice Address - Phone:972-579-5222
Practice Address - Fax:972-579-3900
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7469202K00000X, 2083P0011X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133183708Medicaid
F42220Medicare UPIN
TX133183708Medicaid