1114110640 NPI number — DAVID R. GOTHAM, JR., D.O., INCORPORATED

Table of content: (NPI 1114110640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114110640 NPI number — DAVID R. GOTHAM, JR., D.O., INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID R. GOTHAM, JR., D.O., INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114110640
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7855 WINGATE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANITE BAY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95746-9362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-791-9510
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2204 PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
ROCKLIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95765-4413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-771-9555
Provider Business Practice Location Address Fax Number:
916-771-9556
Provider Enumeration Date:
08/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOTHAM
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-616-0510

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  20A8894 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com