Provider Demographics
NPI:1285670414
Name:GORMAN, JOHN DONNELL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DONNELL
Last Name:GORMAN
Suffix:
Gender:M
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:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440
Mailing Address - Country:US
Mailing Address - Phone:541-687-7134
Mailing Address - Fax:541-687-7135
Practice Address - Street 1:1255 HILYARD STREET
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-687-7134
Practice Address - Fax:541-687-7135
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD143492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2587RMedicaid
WA8425696Medicaid
OR278062Medicaid
AKMD4189RMedicaid
OR278062Medicaid
AK161137Medicare PIN
OR135701Medicare PIN
ORP00383034Medicare PIN
ORP00241418Medicare PIN
OR131749Medicare PIN
AKMD2587RMedicaid
ORP00240046Medicare PIN