Provider Demographics
NPI:1992808232
Name:MCCORD, GARY (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MCCORD
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:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:WELLBORN
Mailing Address - State:TX
Mailing Address - Zip Code:77881-0339
Mailing Address - Country:US
Mailing Address - Phone:979-567-3245
Mailing Address - Fax:979-845-5533
Practice Address - Street 1:1101 WOODSON DR
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:TX
Practice Address - Zip Code:77836-1052
Practice Address - Country:US
Practice Address - Phone:979-567-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG53532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K48UOtherBLUE CROSS BLUE SHIELD
C19078Medicare UPIN
00K48UMedicare ID - Type Unspecified