Provider Demographics
NPI:1689823429
Name:GRECZANIK, RICHARD DAVID (DO)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:GRECZANIK
Suffix:
Gender:M
Credentials:DO
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-2975
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:3593 E GRANDE BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-1400
Practice Address - Country:US
Practice Address - Phone:903-839-2585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009584207Q00000X
OH58.001880207Q00000X
TXR1957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX370175701Medicaid
TX75-0818167-022OtherTRICARE
TX75-2616977-001OtherTRICARE
TX75-2616977-129OtherTRICARE
TXP01877165OtherMEDICARE RAIL ROAD
TX8GQ047OtherBCBS
TX8GQ046OtherBCBS
TX370175702Medicaid
TX75-2616977-002OtherTRICARE
TX75-2616977-028OtherTRICARE
TX8GQ046OtherBCBS
TXP01877165OtherMEDICARE RAIL ROAD