Provider Demographics
NPI:1104960251
Name:GORNY, JOHN RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:GORNY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:665 CAMINO DE LOS MARES
Mailing Address - Street 2:SUITE 203A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2859
Mailing Address - Country:US
Mailing Address - Phone:949-661-3101
Mailing Address - Fax:949-661-2865
Practice Address - Street 1:665 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 203A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2859
Practice Address - Country:US
Practice Address - Phone:949-661-3101
Practice Address - Fax:949-661-2865
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG12635207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953607067OtherTAX ID
CAOOG126350Medicaid
CAOOG126350Medicaid
CAA90216Medicare UPIN
CAAG5315064OtherDEA