Healthcare Provider Details

I. General information

NPI: 1376569657
Provider Name (Legal Business Name): WALLACE G GOSNEY MD & GILBERT R TURNER MD PTRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N 13TH AVE STE 204
UPLAND CA
91786-4965
US

IV. Provider business mailing address

510 N 13TH AVE STE 204
UPLAND CA
91786-4965
US

V. Phone/Fax

Practice location:
  • Phone: 909-920-0525
  • Fax: 909-920-0526
Mailing address:
  • Phone: 909-920-0525
  • Fax: 909-920-0526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA65402
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA65402
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberG67360
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG67360
License Number StateCA

VIII. Authorized Official

Name: DR. BRIAN SPIVACK
Title or Position: PARTNER
Credential: MD
Phone: 909-946-5320