Provider Demographics
NPI:1356342364
Name:GORMAN, MICHAEL JUSTIN (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JUSTIN
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:10521 JEFFREYS ST STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4181
Practice Address - Country:US
Practice Address - Phone:702-269-6345
Practice Address - Fax:702-269-9422
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-04-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO38165207Q00000X
NVDO1423207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDO1423OtherSTATE LICENSE
NV1356342364Medicaid