Provider Demographics
NPI:1093723108
Name:GOURGY, DALIA JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:DALIA
Middle Name:JENNIFER
Last Name:GOURGY
Suffix:
Gender:F
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:PO BOX 398993
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-8993
Mailing Address - Country:US
Mailing Address - Phone:949-588-2190
Mailing Address - Fax:949-588-2199
Practice Address - Street 1:10904 REAGAN ST
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2435
Practice Address - Country:US
Practice Address - Phone:562-596-3140
Practice Address - Fax:562-596-3142
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81125207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G811251Medicaid
CA00G811251OtherBLUE SHIELD
G67225Medicare UPIN
CA00G811251OtherBLUE SHIELD
CACG986YMedicare PIN
CACG986ZMedicare PIN