Provider Demographics
NPI:1104095637
Name:IKE B. GORMAN DPM., PC
Entity type:Organization
Organization Name:IKE B. GORMAN DPM., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IKE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:520-722-5115
Mailing Address - Street 1:PO BOX 69040
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-0009
Mailing Address - Country:US
Mailing Address - Phone:520-722-5115
Mailing Address - Fax:520-722-0611
Practice Address - Street 1:1500 N WILMOT RD
Practice Address - Street 2:SUITE A230
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4416
Practice Address - Country:US
Practice Address - Phone:520-722-5115
Practice Address - Fax:520-722-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ301213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ700981Medicaid
AZT89656Medicare UPIN
AZZ60532Medicare PIN
AZ700981Medicaid