Provider Demographics
NPI:1225221575
Name:GORMLEY, LAUREN A (OD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:A
Last Name:GORMLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 YORK RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6207
Mailing Address - Country:US
Mailing Address - Phone:410-821-9492
Mailing Address - Fax:410-821-9495
Practice Address - Street 1:1209 YORK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-6207
Practice Address - Country:US
Practice Address - Phone:410-821-9490
Practice Address - Fax:410-821-9495
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2073152WL0500X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD016433000Medicaid
MDS049T102Medicare PIN