Provider Demographics
NPI:1114185147
Name:GORMAN, PETER G (DC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 873
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-0873
Mailing Address - Country:US
Mailing Address - Phone:845-628-4900
Mailing Address - Fax:845-628-4549
Practice Address - Street 1:11 MILLER RD
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-2219
Practice Address - Country:US
Practice Address - Phone:845-628-4900
Practice Address - Fax:845-628-4549
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002504-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor