1649281569 NPI number — DEITRICK L GORMAN DO

Table of content: DEITRICK L GORMAN DO (NPI 1649281569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649281569 NPI number — DEITRICK L GORMAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORMAN
Provider First Name:
DEITRICK
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649281569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MEADOWBROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PECOS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79772-6607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-447-0565
Provider Business Mailing Address Fax Number:
432-447-5053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2323 TEXAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PECOS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79772-7338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-447-0565
Provider Business Practice Location Address Fax Number:
432-447-5053
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  N4435 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 211545301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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