Basic Information
| Provider Information | |||||||||
| NPI: | 1043446206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847824 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038777777 | ||||||||
| FaxNumber: | 9038775080 | ||||||||
| Practice Location | |||||||||
| Address1: | 1139 E SONTERRA BLVD STE 205 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782584349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108743359 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10035367 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | P4860 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.