Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | 201441 | LA |
N | 207K00000X | Allergist & Immunologist | L5832 | TX |
Y | 2080P0201X | Pediatric Allergist | 201441 | LA |
NPI | 1649367541 |
---|---|
Provider Name | Theron Garrick Mccormick |
First Address | Baton Rouge, LA 70816-6038 |
Second Address | Baton Rouge, LA 70809-3481 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 05/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1017973 | (05) | LA |
I31514 | (02) | LA |