Provider Demographics
NPI:1114921889
Name:GORACKE, DOUGLAS STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:STEVEN
Last Name:GORACKE
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:PO BOX 19
Mailing Address - Street 2:
Mailing Address - City:HERMANN
Mailing Address - State:MO
Mailing Address - Zip Code:65041-0019
Mailing Address - Country:US
Mailing Address - Phone:573-486-1193
Mailing Address - Fax:573-486-0910
Practice Address - Street 1:509 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-1547
Practice Address - Country:US
Practice Address - Phone:573-486-2191
Practice Address - Fax:573-486-0910
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-22640207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202985016Medicaid
KS100133270AMedicaid
050018992OtherRAILROAD MEDICARE
1114921889OtherNATIONAL PROVIDER IDENTIFICATION
MO202985016Medicaid
1114921889OtherNATIONAL PROVIDER IDENTIFICATION