Healthcare Provider Details

I. General information

NPI: 1285670414
Provider Name (Legal Business Name): JOHN DONNELL GORMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 HILYARD STREET
EUGENE OR
97401
US

IV. Provider business mailing address

PO BOX 53
EUGENE OR
97440
US

V. Phone/Fax

Practice location:
  • Phone: 541-687-7134
  • Fax: 541-687-7135
Mailing address:
  • Phone: 541-687-7134
  • Fax: 541-687-7135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD14349
License Number StateOR

VII. Legacy identifiers

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

# 1
IdentifierMD2587R
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
Identifier8425696
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 3
Identifier278062
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 4
IdentifierMD4189R
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: