Provider Demographics
NPI:1780680165
Name:GORMAN, MARK RICHARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8475 E HARTFORD DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-5477
Mailing Address - Country:US
Mailing Address - Phone:480-591-9345
Mailing Address - Fax:
Practice Address - Street 1:10214 N TATUM BLVD STE B300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-4233
Practice Address - Country:US
Practice Address - Phone:602-954-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0069213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0065330OtherBCBSAZ PROVIDER #
AZ700444OtherAHCCCS
AZT41659Medicare UPIN
AZ7076150001Medicare NSC
AZ7076150001Medicare NSC