Basic Information
| Provider Information | |||||||||
| NPI: | 1861495368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKENS | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILLMORE | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 W. 5TH STREET | ||||||||
| Address2: | SUITE 3142 | ||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4327035299 | ||||||||
| FaxNumber: | 8062126278 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W. 5TH STREET | ||||||||
| Address2: | SUITE 3142 | ||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4327035299 | ||||||||
| FaxNumber: | 4323855354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 01/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | K6238 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 041886501 | 05 | TX | MEDICAID |