Provider Demographics
NPI:1891718755
Name:CORMACK, TRINA S (MD)
Entity Type:Individual
Prefix:
First Name:TRINA
Middle Name:S
Last Name:CORMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5709 FRUITLAND FARM RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-1042
Mailing Address - Country:US
Mailing Address - Phone:409-789-5343
Mailing Address - Fax:
Practice Address - Street 1:1901 NORTH HWY 87
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720
Practice Address - Country:US
Practice Address - Phone:409-789-5343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK21502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117746105Medicaid
TX117746105Medicaid
TXTXB160199Medicare PIN
TX8G5419Medicare ID - Type Unspecified
TX8K3689Medicare PIN
TX00102QMedicare ID - Type Unspecified