Basic Information
Provider Information
NPI: 1003800079
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GROSSNICKLE
FirstName: RICHARD
MiddleName: DEAN
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207W00000XE6388TXY Allopathic & Osteopathic PhysiciansOphthalmology 

ID Information
IDTypeStateIssuerDescription
00SC1101TXBLUE CROSS BLUE SHIELD TXOTHER
11009760205TX MEDICAID


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