Provider Demographics
NPI:1356865109
Name:MCCORMICK, DAUVON LAMAR (CCP)
Entity Type:Individual
Prefix:MR
First Name:DAUVON
Middle Name:LAMAR
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14603 HUEBNER RD STE 28101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5497
Mailing Address - Country:US
Mailing Address - Phone:210-614-7074
Mailing Address - Fax:
Practice Address - Street 1:14603 HUEBNER RD. BLG 28, STE 28101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78203
Practice Address - Country:US
Practice Address - Phone:210-614-7074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXFPF02000050242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist