Healthcare Provider Details

I. General information

NPI: 1104095637
Provider Name (Legal Business Name): IKE B. GORMAN DPM., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WILMOT RD SUITE A230
TUCSON AZ
85712-4416
US

IV. Provider business mailing address

PO BOX 69040
TUCSON AZ
85737-0009
US

V. Phone/Fax

Practice location:
  • Phone: 520-722-5115
  • Fax: 520-722-0611
Mailing address:
  • Phone: 520-722-5115
  • Fax: 520-722-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number301
License Number StateAZ

VIII. Authorized Official

Name: DR. IKE B GORMAN
Title or Position: OWNER
Credential: DPM
Phone: 520-722-5115