Provider Demographics
NPI:1528028115
Name:GORMAN, IKE B (DPM,PC)
Entity Type:Individual
Prefix:
First Name:IKE
Middle Name:B
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DPM,PC
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 69040
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85737
Mailing Address - Country:US
Mailing Address - Phone:520-722-5115
Mailing Address - Fax:520-722-0611
Practice Address - Street 1:1500 N WILMOT RD
Practice Address - Street 2:STE A230
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4416
Practice Address - Country:US
Practice Address - Phone:520-722-5115
Practice Address - Fax:520-722-0611
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ301213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ700981Medicaid
AZZ60532Medicare PIN
T89656Medicare UPIN
AZ700981Medicaid