Basic Information
| Provider Information | |||||||||
| NPI: | 1578637310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | N | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3150 NE 190TH ST APT 104 | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331803175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548068446 | ||||||||
| FaxNumber: | 8663827695 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 NE 164TH ST | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331624100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059457113 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1086 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 084468300 | 05 | FL | MEDICAID |