Healthcare Provider Details

I. General information

NPI: 1699706382
Provider Name (Legal Business Name): LIV ELIZABETH GORLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIV GORLA

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10571 TELEGRAPH RD SUITE 110
GLEN ALLEN VA
23059-4652
US

IV. Provider business mailing address

10571 TELEGRAPH RD SUITE 110
GLEN ALLEN VA
23059-4652
US

V. Phone/Fax

Practice location:
  • Phone: 804-266-9616
  • Fax: 804-266-8908
Mailing address:
  • Phone: 804-266-9616
  • Fax: 804-266-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number057838
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101237839
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: