Provider Demographics
NPI:1881636017
Name:GORMAN, MARK PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PATRICK
Last Name:GORMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:54 ROSSMORE RD
Mailing Address - Street 2:APARTMENT 3
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3665
Mailing Address - Country:US
Mailing Address - Phone:617-803-5585
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:DEPARTMENT OF NEUROLOGY - CHILDREN'S HOSPITAL BOSTON
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-2067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2275772084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2149303Medicaid