Provider Demographics
NPI:1649272832
Name:GORSULOWSKY, DAVID C (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
Last Name:GORSULOWSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:39210 STATE ST
Mailing Address - Street 2:STE 218
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1456
Mailing Address - Country:US
Mailing Address - Phone:510-790-0477
Mailing Address - Fax:510-790-1835
Practice Address - Street 1:39210 STATE ST
Practice Address - Street 2:STE 218
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1456
Practice Address - Country:US
Practice Address - Phone:510-790-0477
Practice Address - Fax:510-790-1835
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC042190174400000X
CAC42190207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA943205645OtherTAX IDENTIFICATION NUMBER
CAC42190OtherCALIFORNIA LICENSE NUMBER
CA070008967OtherRAILROAD MEDICARE NUMBER
CAZZZ43507ZMedicare PIN
CAC42190OtherCALIFORNIA LICENSE NUMBER
CA943205645OtherTAX IDENTIFICATION NUMBER