Provider Demographics
NPI:1598709115
Name:GORMAN, KAREN M (OD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:M
Last Name:GORMAN
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 1:3602 WEST COLONY SQUARE
Mailing Address - Street 2:
Mailing Address - City:ST JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1713 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-6446
Practice Address - Country:US
Practice Address - Phone:660-582-8911
Practice Address - Fax:660-582-2545
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO 02665152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0002594Medicare ID - Type Unspecified