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NPI Code Detail

MEDICARE: DEITRICK LEELLEN GORMAN DO

MEDICARE: DEITRICK LEELLEN GORMAN DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician20A21341CA
2207Q00000XFamily Medicine PhysicianN4435TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1649281569
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEITRICK LEELLEN GORMAN DO
Provider Business Mailing Address
First Line : PO BOX 255228
Second Line :
City : SACRAMENTO
State : CA
Zip : 95865-5228
Country : US
Telephone Number : 800-470-0071
Fax Number : 916-854-6769
Provider Business Practice Location Address
First Line : 600 COFFEE RD
Second Line :
City : MODESTO
State : CA
Zip : 95355-4201
Country : US
Telephone Number : 209-550-4755
Fax Number : 510-491-7522
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/10/2006
Last Update Date : 05/26/2026

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