Provider Demographics
NPI:1528239571
Name:GOSLA, FAKIRMOHMED MAHMED (MD)
Entity type:Individual
Prefix:
First Name:FAKIRMOHMED
Middle Name:MAHMED
Last Name:GOSLA
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:PO BOX 60265
Mailing Address - Street 2:15 VACAVILLE
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602
Mailing Address - Country:US
Mailing Address - Phone:714-389-2535
Mailing Address - Fax:
Practice Address - Street 1:15 VACAVILLE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602
Practice Address - Country:US
Practice Address - Phone:714-389-2535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFE33960208100000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3864816Medicaid
A84547Medicare UPIN