Provider Demographics
NPI:1982751814
Name:GOUGH, GALAL SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GALAL
Middle Name:SAMUEL
Last Name:GOUGH
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 1:8655 FRESNO CIR UNIT 502C
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-5731
Mailing Address - Country:US
Mailing Address - Phone:310-387-5585
Mailing Address - Fax:
Practice Address - Street 1:13132 STUDEBAKER RD STE 9
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2575
Practice Address - Country:US
Practice Address - Phone:562-868-3751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21076207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA21076OtherMEDICAL LICENSE
CAA22443Medicare UPIN