Provider Demographics
NPI:1457469249
Name:GOURLEY, GEORGE C (DO)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:C
Last Name:GOURLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1548
Mailing Address - Country:US
Mailing Address - Phone:013-741-8018
Mailing Address - Fax:012-168-3578
Practice Address - Street 1:585 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1548
Practice Address - Country:US
Practice Address - Phone:013-741-8018
Practice Address - Fax:801-216-8357
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT870469392207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC90872Medicare UPIN