Provider Demographics
NPI:1851336390
Name:CORNEL VAN GORP, MD, PA
Entity Type:Organization
Organization Name:CORNEL VAN GORP, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CORNEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:VAN GORP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-358-2626
Mailing Address - Street 1:3501 S SONCY RD
Mailing Address - Street 2:SUITE 137
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6407
Mailing Address - Country:US
Mailing Address - Phone:806-358-2626
Mailing Address - Fax:806-358-2985
Practice Address - Street 1:3501 S SONCY RD
Practice Address - Street 2:SUITE 137
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-6407
Practice Address - Country:US
Practice Address - Phone:806-358-2626
Practice Address - Fax:806-358-2985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00549VMedicare ID - Type UnspecifiedGROUP NUMBER