Provider Demographics
NPI:1346374378
Name:GOURLAY, STUART J (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:J
Last Name:GOURLAY
Suffix:
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 1:1430 TARA HILLS DR
Mailing Address - Street 2:STE. D
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2580
Mailing Address - Country:US
Mailing Address - Phone:510-724-5714
Mailing Address - Fax:510-724-5733
Practice Address - Street 1:1430 TARA HILLS DR
Practice Address - Street 2:STE. D
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2580
Practice Address - Country:US
Practice Address - Phone:510-724-5714
Practice Address - Fax:510-724-5733
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA022868208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0058731Medicaid
CAZZZ39085ZMedicare ID - Type Unspecified
CAGR0058731Medicaid