Provider Demographics
NPI:1336463447
Name:GOURLEY, ERIC
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:GOURLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CROSSROADS DR STE 306
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5437
Mailing Address - Country:US
Mailing Address - Phone:443-738-2889
Mailing Address - Fax:443-471-8540
Practice Address - Street 1:11960 LIONESS WAY STE 210
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-5644
Practice Address - Country:US
Practice Address - Phone:303-695-6106
Practice Address - Fax:303-695-1211
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0064296208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODR.0064296OtherSTATE LICENSE