Provider Demographics
NPI:1093726945
Name:GOSPE, SIDNEY MALOCH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:MALOCH
Last Name:GOSPE
Suffix:JR
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 1:1017 VALLEY ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-2991
Mailing Address - Country:US
Mailing Address - Phone:206-261-8786
Mailing Address - Fax:
Practice Address - Street 1:1017 VALLEY ROSE WAY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27712-2991
Practice Address - Country:US
Practice Address - Phone:206-261-8786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG14132084N0402X
NC2226102084N0402X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C59224Medicare UPIN