Provider Demographics
NPI:1093084881
Name:GERALD T GOSTANIAN MD INC
Entity Type:Organization
Organization Name:GERALD T GOSTANIAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSTANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-640-4650
Mailing Address - Street 1:400 NEWPORT CENTER DR STE 202A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7680
Mailing Address - Country:US
Mailing Address - Phone:949-640-4650
Mailing Address - Fax:
Practice Address - Street 1:400 NEWPORT CENTER DR STE 202A
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7680
Practice Address - Country:US
Practice Address - Phone:949-640-4650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22986261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22986OtherSTATE LICENSE
CAA22986OtherSTATE LICENSE