Basic Information
| Provider Information | |||||||||
| NPI: | 1730381310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8173322304 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 HEMPHILL ST. | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173324060 | ||||||||
| FaxNumber: | 8173322304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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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 | 207Y00000X | 201403 | LA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | P0970 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 282132402 | 05 | TX | MEDICAID | P01071869 | 01 | TX | MEDICARE RAILROAD | OTHER |