Provider Demographics
NPI:1659791259
Name:CORMACK, JUSTIN I (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:CORMACK
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:EMERGENCY
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4917
Mailing Address - Country:US
Mailing Address - Phone:817-702-8773
Mailing Address - Fax:817-702-1143
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:EMERGENCY
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-8773
Practice Address - Fax:817-702-1143
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ9797207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program