Provider Demographics
NPI:1740221092
Name:GOURLAY, DAVID M (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:M
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 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6550
Mailing Address - Fax:414-266-6579
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6550
Practice Address - Fax:414-266-6579
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI468532086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740221092Medicaid
WI1740221092Medicaid
H32542Medicare UPIN
WI680860511Medicare PIN