MEDICARE: DR. JOHN ERVIN DICKSON 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	207R00000X	Internal Medicine Physician	J7470	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0052HL	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1154467116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ERVIN DICKSON M.D.

Provider Business Mailing Address
First Line	:	325 E SONTERRA BLVD
Second Line	:	SUITE 200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4054
Country	:	US
Telephone Number	:	210-402-3069
Fax Number	:	210-424-0631

Provider Business Practice Location Address
First Line	:	325 E SONTERRA BLVD
Second Line	:	SUITE 200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4054
Country	:	US
Telephone Number	:	210-402-3069
Fax Number	:	210-424-0631

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/09/2007

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