Provider Demographics
NPI:1073567442
Name:GORNIOWSKY, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GORNIOWSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 REDONDO BEACH BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-3306
Mailing Address - Country:US
Mailing Address - Phone:310-214-8677
Mailing Address - Fax:310-921-1718
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:SUITE 428
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6313
Practice Address - Country:US
Practice Address - Phone:310-306-1888
Practice Address - Fax:310-577-8290
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G279230Medicaid
CAAG6571233OtherDEA NUMBER
CAWG27923DMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAA9218Medicare UPIN