Provider Demographics
NPI:1801831599
Name:GOMERSALL, JANICE R (MD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:R
Last Name:GOMERSALL
Suffix:
Gender:F
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:PO BOX 16900
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-6900
Mailing Address - Country:US
Mailing Address - Phone:406-327-4620
Mailing Address - Fax:406-549-5928
Practice Address - Street 1:2835 FORT MISSOULA RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7423
Practice Address - Country:US
Practice Address - Phone:406-327-3920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1801831599Medicaid
E74817Medicare UPIN
MT011001547Medicare PIN