Provider Demographics
NPI:1932110806
Name:DODSON, JERRY W (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:DODSON
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 1:417 MONTECITO DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-7342
Mailing Address - Country:US
Mailing Address - Phone:325-659-1787
Mailing Address - Fax:325-659-5501
Practice Address - Street 1:417 MONTECITO DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-7342
Practice Address - Country:US
Practice Address - Phone:325-659-1787
Practice Address - Fax:325-659-5501
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD81952084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
82-0368325OtherTAX ID
TX098697802Medicaid
82-0368325OtherTAX ID