Provider Demographics
NPI:1053302158
Name:GORMAN, INGRID (MD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3718
Mailing Address - Country:US
Mailing Address - Phone:978-263-1131
Mailing Address - Fax:
Practice Address - Street 1:321 MAIN ST
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3718
Practice Address - Country:US
Practice Address - Phone:978-263-1131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3143783Medicaid
MA3143783Medicaid
MAA20534Medicare ID - Type Unspecified