1861495368 NPI number — DEBORAH L PICKENS M.D.

Table of content: DEBORAH L PICKENS M.D. (NPI 1861495368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861495368 NPI number — DEBORAH L PICKENS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKENS
Provider First Name:
DEBORAH
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILLMORE
Provider Other First Name:
DEBORAH
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1861495368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 W. 5TH STREET
Provider Second Line Business Mailing Address:
SUITE 3142
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-703-5299
Provider Business Mailing Address Fax Number:
806-212-6278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 W. 5TH STREET
Provider Second Line Business Practice Location Address:
SUITE 3142
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-703-5299
Provider Business Practice Location Address Fax Number:
432-385-5354
Provider Enumeration Date:
05/27/2005

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: 2080N0001X , with the licence number:  K6238 , 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: 041886501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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