Provider Demographics
NPI:1497759815
Name:MCCORMICK, PAUL W (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:MCCORMICK
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 1:3560 DELAWARE ST
Mailing Address - Street 2:209
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3059
Mailing Address - Country:US
Mailing Address - Phone:409-899-3682
Mailing Address - Fax:
Practice Address - Street 1:3560 DELAWARE ST
Practice Address - Street 2:209
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3059
Practice Address - Country:US
Practice Address - Phone:409-899-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0770174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134477205Medicaid
TX134477205Medicaid
TXE14275Medicare UPIN