MEDICARE: KAREN DELANE DICKERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	J4083	TX
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	J4083	TX

General Provider Information

NPI Number	:	1861475956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN DELANE DICKERSON M.D.

Provider Business Mailing Address
First Line	:	1675 REPUBLIC PKWY
Second Line	:	STE 201
City	:	MESQUITE
State	:	TX
Zip	:	75150-6902
Country	:	US
Telephone Number	:	972-850-9179
Fax Number	:	877-720-5614

Provider Business Practice Location Address
First Line	:	1675 REPUBLIC PKWY
Second Line	:	STE 201
City	:	MESQUITE
State	:	TX
Zip	:	75150-6902
Country	:	US
Telephone Number	:	972-672-8484
Fax Number	:	972-692-8227

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	03/30/2021

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