Provider Demographics
NPI:1891765418
Name:GORMAN, MARK JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
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 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:49 SPRING ST
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8926
Practice Address - Country:US
Practice Address - Phone:207-883-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD212322084V0102X, 2084N0400X
VT04200110562084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400334172Medicare PIN
MEE400334170Medicare PIN