Healthcare Provider Details

I. General information

NPI: 1013970680
Provider Name (Legal Business Name): GREGG JEFFRY DIMMICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 REGIONAL MEDICAL DR
WHARTON TX
77488-9719
US

IV. Provider business mailing address

2100 REGIONAL MEDICAL DR
WHARTON TX
77488-9719
US

V. Phone/Fax

Practice location:
  • Phone: 979-532-1700
  • Fax: 979-532-6793
Mailing address:
  • Phone: 979-532-1700
  • Fax: 979-532-6793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberF0169
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: