Provider Demographics
NPI:1447293840
Name:FAIN, JERRY DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DEAN
Last Name:FAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:901 W 38TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1165
Practice Address - Country:US
Practice Address - Phone:512-419-9733
Practice Address - Fax:512-451-3709
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH4310207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BP225OtherBCBS OF TX
TXP00645999OtherRAILROAD MEDICARE
TX131313207Medicaid
TX131313202Medicaid
TX830004599OtherRAILROAD MEDICARE NUMBER
TX131313208Medicaid
TX8L1727Medicare PIN
TX830004599OtherRAILROAD MEDICARE NUMBER
TX131313207Medicaid
TX8L1726Medicare PIN