Provider Demographics
NPI:1831302637
Name:GORMAN, KIERAN CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:KIERAN
Middle Name:CHARLES
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HARRISON ST
Mailing Address - Street 2:APT 15K
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-2742
Mailing Address - Country:US
Mailing Address - Phone:516-241-8839
Mailing Address - Fax:
Practice Address - Street 1:17935 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4631
Practice Address - Country:US
Practice Address - Phone:718-262-0220
Practice Address - Fax:718-262-0221
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05244Medicare UPIN