Basic Information
| Provider Information | |||||||||
| NPI: | 1801090832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDICK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 845347 | ||||||||
| Address2: | HOUSE STAFF & GME | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908058 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BOULEVARD | ||||||||
| Address2: | HOUSE STAFF & GME | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753909257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146458995 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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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 | 2085R0202X | N1097 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | N1097 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | BP3-0029592 | 01 | INSTITUTIONAL PERMIT | OTHER |