1093084881 NPI number — GERALD T GOSTANIAN MD INC

Table of content: (NPI 1093084881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093084881 NPI number — GERALD T GOSTANIAN MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERALD T GOSTANIAN MD INC
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:
1093084881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 NEWPORT CENTER DR STE 202A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660-7680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-640-4650
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 NEWPORT CENTER DR STE 202A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92660-7680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-640-4650
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GOSTANIAN
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
949-640-4650

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  A22986 , 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)

  • Identifier: A22986 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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