Healthcare Provider Details

I. General information

NPI: 1922158500
Provider Name (Legal Business Name): CORY V TRICKETT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3183 W STATE ST
BRISTOL TN
37620-1712
US

IV. Provider business mailing address

3551 ROGER BROOKE DR MCHE-QD(CREDS)
SAN ANTONIO TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 423-764-7131
  • Fax: 423-245-3136
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number73663
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number10791
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number3466
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: