Provider Demographics
NPI:1023102605
Name:O'GORMAN, KIMBERLY ANN (DC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:O'GORMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 E COMMERCIAL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334
Mailing Address - Country:US
Mailing Address - Phone:954-938-4321
Mailing Address - Fax:954-938-4322
Practice Address - Street 1:1730 E COMMERCIAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334
Practice Address - Country:US
Practice Address - Phone:954-938-4321
Practice Address - Fax:954-938-4322
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8533111N00000X
FLCH8533261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
76960Medicare PIN
493010Medicare UPIN