Provider Demographics
NPI:1417915778
Name:GOSNEY, WALLACE GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:GEORGE
Last Name:GOSNEY
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 1:901 SAN BERNARDINO RD
Mailing Address - Street 2:STE 301
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4912
Mailing Address - Country:US
Mailing Address - Phone:909-946-6221
Mailing Address - Fax:909-949-3802
Practice Address - Street 1:901 SAN BERNARDINO RD
Practice Address - Street 2:STE 301
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4912
Practice Address - Country:US
Practice Address - Phone:909-946-6221
Practice Address - Fax:909-949-3802
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA19860174400000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A198600Medicaid
CA00A198600Medicaid
CAMMM00107MMedicare ID - Type Unspecified