Provider Demographics
NPI:1770556367
Name:GORMAN, RYAN A (DO)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:A
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 SOUTH RD STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2483
Practice Address - Country:US
Practice Address - Phone:860-284-9544
Practice Address - Fax:860-284-9548
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0078514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2035987Medicaid
MAI00137Medicare UPIN
MD712L/472364YBPGMedicare PIN
MAA36294Medicare ID - Type Unspecified