Provider Demographics
NPI:1205213790
Name:GORMAN, MITCHELL DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DOUGLAS
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 READE PL
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-3947
Mailing Address - Country:US
Mailing Address - Phone:845-454-8500
Mailing Address - Fax:
Practice Address - Street 1:45 READE PL
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3947
Practice Address - Country:US
Practice Address - Phone:845-454-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311152-01208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery