Healthcare Provider Details

I. General information

NPI: 1336709625
Provider Name (Legal Business Name): BRENDAN THOMAS GORMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 MCINTOSH CIR STE 200
JOPLIN MO
64804-3604
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-0540
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-3703
  • Fax:
Mailing address:
  • Phone: 409-772-2091
  • Fax: 409-772-5144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberBP10068816
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2024031103
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: