Provider Demographics
NPI:1649281569
Name:GORMAN, DEITRICK L (DO)
Entity type:Individual
Prefix:
First Name:DEITRICK
Middle Name:L
Last Name:GORMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772-6607
Mailing Address - Country:US
Mailing Address - Phone:432-447-0565
Mailing Address - Fax:432-447-5053
Practice Address - Street 1:2349 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:TX
Practice Address - Zip Code:79772-2251
Practice Address - Country:US
Practice Address - Phone:432-447-0565
Practice Address - Fax:432-447-5053
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211545301Medicaid
TX8L25465Medicare PIN