Provider Demographics
NPI:1033325097
Name:FOOTCARE CENTER - DR. MARK GORMAN, PC
Entity Type:Organization
Organization Name:FOOTCARE CENTER - DR. MARK GORMAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:623-934-3211
Mailing Address - Street 1:8608 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-5404
Mailing Address - Country:US
Mailing Address - Phone:623-934-3211
Mailing Address - Fax:623-930-1891
Practice Address - Street 1:8608 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-5404
Practice Address - Country:US
Practice Address - Phone:623-934-3211
Practice Address - Fax:623-930-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0069213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ65393Medicare ID - Type Unspecified