Provider Demographics
NPI:1861495368
Name:PICKENS, DEBORAH L (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:PICKENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:L
Other - Last Name:GILLMORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:701 W. 5TH STREET
Mailing Address - Street 2:SUITE 3142
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763
Mailing Address - Country:US
Mailing Address - Phone:432-703-5299
Mailing Address - Fax:806-212-6278
Practice Address - Street 1:701 W. 5TH STREET
Practice Address - Street 2:SUITE 3142
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763
Practice Address - Country:US
Practice Address - Phone:432-703-5299
Practice Address - Fax:432-385-5354
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK62382080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041886501Medicaid
G81351Medicare UPIN
TX83188BMedicare ID - Type UnspecifiedTRAILBLAZER HEALTH ENTERP