Provider Demographics
NPI:1760511315
Name:WEST TEXAS NEUROSURGERY PA
Entity Type:Organization
Organization Name:WEST TEXAS NEUROSURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-580-4700
Mailing Address - Street 1:8050 E HIGHWAY 191
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-8613
Mailing Address - Country:US
Mailing Address - Phone:432-580-4700
Mailing Address - Fax:432-332-2678
Practice Address - Street 1:8050 E HIGHWAY 191
Practice Address - Street 2:SUITE 212
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8613
Practice Address - Country:US
Practice Address - Phone:432-580-4700
Practice Address - Fax:432-332-2678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4342207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166114201Medicaid
TX0004QFOtherBCBS GROUP NUMBER
TXL4342OtherTEXAS LICENSE
TX165059001Medicaid
TX8AJ418OtherBCBS INDIVIDUAL NUMBER
TX8AJ418OtherBCBS INDIVIDUAL NUMBER
TX165059001Medicaid
TX166114201Medicaid
TXG56522Medicare UPIN