Provider Demographics
NPI:1730178179
Name:O'GORMAN, JOSEPH D (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:O'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 1:4300B W RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2568
Mailing Address - Country:US
Mailing Address - Phone:228-863-7393
Mailing Address - Fax:228-864-0546
Practice Address - Street 1:4300B W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2568
Practice Address - Country:US
Practice Address - Phone:228-863-7393
Practice Address - Fax:228-864-0546
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13450207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
390004123OtherRAILROAD MEDICARE
MS115334Medicaid
390000086Medicare PIN
E53179Medicare UPIN
C02221Medicare PIN
390004123OtherRAILROAD MEDICARE