Provider Demographics
NPI:1598070435
Name:HUSSAM EL GOHARY MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:HUSSAM EL GOHARY MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUSSAM
Authorized Official - Middle Name:IBRAHIM
Authorized Official - Last Name:ELGOHARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-964-0458
Mailing Address - Street 1:2342 SHATTUCK AVE
Mailing Address - Street 2:#363
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1517
Mailing Address - Country:US
Mailing Address - Phone:510-964-0458
Mailing Address - Fax:510-964-0476
Practice Address - Street 1:2001 DWIGHT WAY RM 2350
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2608
Practice Address - Country:US
Practice Address - Phone:510-204-4738
Practice Address - Fax:510-204-5892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37602208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A376021Medicaid
CA00A376021Medicare PIN
CAE39699Medicare UPIN