Provider Demographics
NPI:1447797014
Name:DICKERSON DALLAS PAIN ON PA
Entity type:Organization
Organization Name:DICKERSON DALLAS PAIN ON PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:DELANE
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-672-8484
Mailing Address - Street 1:POST OFFICE BOX 196134
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-8621
Mailing Address - Country:US
Mailing Address - Phone:972-672-8484
Mailing Address - Fax:972-692-8227
Practice Address - Street 1:1675 REPUBLIC PKWY STE 201
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6902
Practice Address - Country:US
Practice Address - Phone:972-672-8484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty