Healthcare Provider Details

I. General information

NPI: 1952667792
Provider Name (Legal Business Name): ROBERT GOUSSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E HERNDON AVE
FRESNO CA
93720-3391
US

IV. Provider business mailing address

1630 E HERNDON AVE
FRESNO CA
93720-3391
US

V. Phone/Fax

Practice location:
  • Phone: 559-290-7050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA149982
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: