Basic Information
| Provider Information | |||||||||
| NPI: | 1780680165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8475 E HARTFORD DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852555477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805919345 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10214 N TATUM BLVD STE B300 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850284233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029540777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 0069 | AZ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0065330 | 01 | AZ | BCBSAZ PROVIDER # | OTHER | 700444 | 01 | AZ | AHCCCS | OTHER |