MEDICARE: DR. JERRY 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	174400000X	Specialist	D4091	TX

General Provider Information

NPI Number	:	1285757112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY ERVIN DICKSON M.D.

Provider Business Mailing Address
First Line	:	8945 LONG POINT RD
Second Line	:	SUITE 101
City	:	HOUSTON
State	:	TX
Zip	:	77055-3034
Country	:	US
Telephone Number	:	713-461-8400
Fax Number	:

Provider Business Practice Location Address
First Line	:	8945 LONG POINT RD
Second Line	:	SUITE 101
City	:	HOUSTON
State	:	TX
Zip	:	77055-3034
Country	:	US
Telephone Number	:	713-461-8400
Fax Number	:

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

Provider Enumeration Date	:	04/07/2007
Last Update Date	:	07/08/2007

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