Provider Demographics
NPI:1306806914
Name:HACKETHORN, DAVID LYON (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LYON
Last Name:HACKETHORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:
Practice Address - Street 1:1700 UNIVERSITY DR E
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840
Practice Address - Country:US
Practice Address - Phone:979-691-3300
Practice Address - Fax:979-691-3527
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4377207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX807442OtherBLUE SHIELD
TX1010084-03Medicaid
TX110220531OtherRR/MEDICARE
TXB23231Medicare UPIN
TX1010084-03Medicaid