Provider Demographics
NPI:1730381310
Name:DEAN, MARC RICHARD (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:RICHARD
Last Name:DEAN
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:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-332-2304
Practice Address - Street 1:901 HEMPHILL ST.
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3111
Practice Address - Country:US
Practice Address - Phone:817-332-4060
Practice Address - Fax:817-332-2304
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201403207Y00000X
TXP0970207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX282132402Medicaid
TXP01071869OtherMEDICARE RAILROAD