Healthcare Provider Details

I. General information

NPI: 1811156763
Provider Name (Legal Business Name): WAMDA GOREAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2374 E PACIFICA PL
RANCHO DOMINGUEZ CA
90220-6214
US

IV. Provider business mailing address

2374 E PACIFICA PL
RANCHO DOMINGUEZ CA
90220-6214
US

V. Phone/Fax

Practice location:
  • Phone: 310-225-3221
  • Fax: 310-698-7040
Mailing address:
  • Phone: 310-225-3221
  • Fax: 310-698-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number307880
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number6945
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number14753
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA118823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: