Provider Demographics
NPI:1922029479
Name:GORMAN, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:GORMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:E
Other - Last Name:RYAN-GORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2651 SOUTH AVE W
Mailing Address - Street 2:VILLAGE HEALTH CARE CENTER
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-6405
Mailing Address - Country:US
Mailing Address - Phone:406-329-5623
Mailing Address - Fax:406-543-7230
Practice Address - Street 1:2651 SOUTH AVE W
Practice Address - Street 2:VILLAGE HEALTLH CARE CENTER
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-6405
Practice Address - Country:US
Practice Address - Phone:406-728-7388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7440207Q00000X
MT79029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0059585Medicaid
MT0059585Medicaid
MTE61916Medicare UPIN