Provider Demographics
NPI:1760603302
Name:GORMAN, LARRY MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:MICHAEL
Last Name:GORMAN
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:P.O. BOX 960
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337
Mailing Address - Country:US
Mailing Address - Phone:360-478-2366
Mailing Address - Fax:360-373-2096
Practice Address - Street 1:616 SIXTH STREET
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98337
Practice Address - Country:US
Practice Address - Phone:360-377-3776
Practice Address - Fax:360-479-0038
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012059207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1297605Medicaid
WA1297605Medicaid
WAA06925Medicare UPIN