Provider Demographics
NPI:1699856419
Name:GORMAN, DOUGLAS EDWARD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:GORMAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1920 CHADWICK DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3471
Mailing Address - Country:US
Mailing Address - Phone:601-373-3730
Mailing Address - Fax:601-372-7431
Practice Address - Street 1:1920 CHADWICK DR
Practice Address - Street 2:SUITE 108
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3471
Practice Address - Country:US
Practice Address - Phone:601-373-3730
Practice Address - Fax:601-372-7431
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS082612082S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640650720OtherCORP TAX ID
MS00010048Medicaid
MSB65897Medicare UPIN
MS00010048Medicaid