Healthcare Provider Details

I. General information

NPI: 1821162140
Provider Name (Legal Business Name): GERALD W. BOURNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

IV. Provider business mailing address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

V. Phone/Fax

Practice location:
  • Phone: 925-370-5973
  • Fax:
Mailing address:
  • Phone: 925-370-5973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG61089
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG61089
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: