Provider Demographics
NPI:1023009297
Name:GOTHAM, DAVID R JR (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:GOTHAM
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2204 PLAZA DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4413
Mailing Address - Country:US
Mailing Address - Phone:916-771-9555
Mailing Address - Fax:916-771-9556
Practice Address - Street 1:2204 PLAZA DR
Practice Address - Street 2:SUITE 210
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-4413
Practice Address - Country:US
Practice Address - Phone:916-771-9555
Practice Address - Fax:916-771-9556
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2009-04-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A8894207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX88940Medicaid
CA020A88940Medicare ID - Type Unspecified
CA00AX88940Medicaid