Provider Demographics
NPI:1598718744
Name:DE GOURVILLE, ROBERT EVERETT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EVERETT
Last Name:DE GOURVILLE
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 1:777 CLEVELAND AVE SW
Mailing Address - Street 2:#400
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-7129
Mailing Address - Country:US
Mailing Address - Phone:404-766-3337
Mailing Address - Fax:
Practice Address - Street 1:777 CLEVELAND AVE SW
Practice Address - Street 2:#400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7129
Practice Address - Country:US
Practice Address - Phone:404-766-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034572208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA30833819DMedicaid
GA30833819DMedicaid