1467505404 NPI number — DICKERSON PEDIATRICS, P.A.

Table of content: (NPI 1467505404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467505404 NPI number — DICKERSON PEDIATRICS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DICKERSON PEDIATRICS, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467505404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16985
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77496-6985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-491-5439
Provider Business Mailing Address Fax Number:
281-240-0577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4760 SWEETWATER BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SUGAR LAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77479-3148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-491-5439
Provider Business Practice Location Address Fax Number:
281-240-0577
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DICKERSON
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE COMMITTEE MEMBER
Authorized Official Telephone Number:
832-643-7047

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  K7434 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com