Provider Demographics
NPI:1942230784
Name:GORMALLY, ERIC P (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:P
Last Name:GORMALLY
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:PO BOX 36446
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85740-6446
Mailing Address - Country:US
Mailing Address - Phone:520-722-3777
Mailing Address - Fax:
Practice Address - Street 1:8333 N SILVERBELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743-7373
Practice Address - Country:US
Practice Address - Phone:520-202-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C99567Medicare UPIN