Healthcare Provider Details

I. General information

NPI: 1033325097
Provider Name (Legal Business Name): FOOTCARE CENTER - DR. MARK GORMAN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8608 N 59TH AVE
GLENDALE AZ
85302-5404
US

IV. Provider business mailing address

8608 N 59TH AVE
GLENDALE AZ
85302-5404
US

V. Phone/Fax

Practice location:
  • Phone: 623-934-3211
  • Fax: 623-930-1891
Mailing address:
  • Phone: 623-934-3211
  • Fax: 623-930-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0069
License Number StateAZ

VIII. Authorized Official

Name: DR. MARK RICHARD GORMAN
Title or Position: CEO
Credential: D.P.M.
Phone: 623-934-3211