Healthcare Provider Details

I. General information

NPI: 1841487337
Provider Name (Legal Business Name): FREMONT DERMATOLOGY MEDICAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39210 STATE ST STE 218
FREMONT CA
94538-1456
US

IV. Provider business mailing address

39210 STATE ST STE 218
FREMONT CA
94538-1456
US

V. Phone/Fax

Practice location:
  • Phone: 510-790-0477
  • Fax:
Mailing address:
  • Phone: 510-790-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC042190
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID C GORSULOWSKY
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 510-790-0477