Provider Demographics
NPI:1386629210
Name:GORMLEY, DANIEL E (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:GORMLEY
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 1:412 W CARROLL AVE
Mailing Address - Street 2:STE 207
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4240
Mailing Address - Country:US
Mailing Address - Phone:626-963-7684
Mailing Address - Fax:626-963-0575
Practice Address - Street 1:412 W CARROLL AVE
Practice Address - Street 2:STE 207
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4240
Practice Address - Country:US
Practice Address - Phone:626-963-7684
Practice Address - Fax:626-963-0575
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21148207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22480Medicare UPIN
CAWA21148BMedicare PIN