Basic Information
| Provider Information | |||||||||
| NPI: | 1003800079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSSNICKLE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2615 NE LOOP 286 | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754603444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067850083 | ||||||||
| FaxNumber: | 9037852947 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 NE LOOP 286 | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754603444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067850083 | ||||||||
| FaxNumber: | 9037852947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | E6388 | TX | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 110097602 | 05 | TX | MEDICAID | 00SC11 | 01 | TX | BLUE CROSS BLUE SHIELD TX | OTHER |