Provider Demographics
NPI:1922101971
Name:DANIEL E GORMLEY MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DANIEL E GORMLEY MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GORMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-963-7684
Mailing Address - Street 1:412 W CARROLL AVE
Mailing Address - Street 2:SUITE #207
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4280
Mailing Address - Country:US
Mailing Address - Phone:626-963-7684
Mailing Address - Fax:626-963-0575
Practice Address - Street 1:412 W CARROLL AVE
Practice Address - Street 2:SUITE #207
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4280
Practice Address - Country:US
Practice Address - Phone:626-963-7684
Practice Address - Fax:626-963-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21148207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A22480Medicare UPIN
CAW21637Medicare PIN