Basic Information
Provider Information
NPI: 1003805789
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PICKARD
FirstName: JOHN
MiddleName: LANCE
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: PICKARD
OtherFirstName: LANCE
OtherMiddleName:  
OtherNamePrefix: DR.
OtherNameSuffix:  
OtherCredential: MD
OtherLastNameType: 5
Mailing Information
Address1: 3600 GASTON AVE
Address2: SUITE 1205
City: DALLAS
State: TX
PostalCode: 752461800
CountryCode: US
TelephoneNumber: 2146928262
FaxNumber: 2146964190
Practice Location
Address1: 4370 MEDICAL ARTS DR
Address2: SUITE 105
City: FLOWER MOUND
State: TX
PostalCode: 750281712
CountryCode: US
TelephoneNumber: 2146911902
FaxNumber: 2145132059
Other Information
ProviderEnumerationDate: 10/17/2005
LastUpdateDate: 01/31/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208800000X27987OKY Allopathic & Osteopathic PhysiciansUrology 

ID Information
IDTypeStateIssuerDescription
04532920205TX MEDICAID
04532920305TX MEDICAID


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