Provider Demographics
NPI:1114110640
Name:DAVID R. GOTHAM, JR., D.O., INCORPORATED
Entity Type:Organization
Organization Name:DAVID R. GOTHAM, JR., D.O., INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOTHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:916-616-0510
Mailing Address - Street 1:7855 WINGATE CT
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9362
Mailing Address - Country:US
Mailing Address - Phone:916-791-9510
Mailing Address - Fax:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8894207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty