Provider Demographics
NPI:1659379469
Name:GORUM, WENDELL JOSEPH II (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:JOSEPH
Last Name:GORUM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1503 GRAVESEND NECK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4428
Mailing Address - Country:US
Mailing Address - Phone:718-479-3303
Mailing Address - Fax:646-569-6993
Practice Address - Street 1:1503 GRAVESEND NECK RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4428
Practice Address - Country:US
Practice Address - Phone:718-479-3303
Practice Address - Fax:646-569-6993
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248330207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03078360Medicaid
H68137Medicare UPIN
NY03078360Medicaid