Provider Demographics
NPI:1649367541
Name:MCCORMICK, THERON GARRICK (MD)
Entity type:Individual
Prefix:
First Name:THERON
Middle Name:GARRICK
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0011
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:8200 CONSTANTIN BLVD FL 3
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3481
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-765-4378
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201441207K00000X, 2080P0201X
TXL5832207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1017973Medicaid
LAI31514Medicare UPIN
LA4K762BC14Medicare PIN
LA4K762DX80Medicare PIN