Provider Demographics
NPI:1194969204
Name:GOURLEY, JEFFREY RYAN (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RYAN
Last Name:GOURLEY
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 1:110 KINGSLEY LN STE 305
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4617
Mailing Address - Country:US
Mailing Address - Phone:757-889-5422
Mailing Address - Fax:757-889-5450
Practice Address - Street 1:110 KINGLEY LANE
Practice Address - Street 2:SUITE 305
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4617
Practice Address - Country:US
Practice Address - Phone:757-889-5942
Practice Address - Fax:757-889-5450
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012454622085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV1422AMedicare PIN