Provider Demographics
NPI:1083659817
Name:GOSS, GARY JAY (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAY
Last Name:GOSS
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 1:5528 E LA PALMA AVE
Mailing Address - Street 2:SUITE 4-A
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-2115
Mailing Address - Country:US
Mailing Address - Phone:714-970-0200
Mailing Address - Fax:714-970-0270
Practice Address - Street 1:5528 E LA PALMA AVE
Practice Address - Street 2:SUITE 4-A
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-2115
Practice Address - Country:US
Practice Address - Phone:714-970-0200
Practice Address - Fax:714-970-0270
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA369062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A369060Medicaid
CAWA36906BMedicare PIN
CAE85772Medicare UPIN
CA00A369061Medicare PIN
CAWA36906LMedicare PIN
CA00A369060Medicare PIN
CAWA36906KMedicare PIN
CA00A369060Medicaid