MEDICARE: DR. CONRAD GOROSPE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZC0006X	Clinical Pathology Physician	G39505	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G39505	OTHER	CA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1134399173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONRAD GOROSPE M.D.

Provider Business Mailing Address
First Line	:	18800 AMAR RD
Second Line	:	B-9
City	:	WALNUT
State	:	CA
Zip	:	91789-4166
Country	:	US
Telephone Number	:	626-839-4696
Fax Number	:	626-965-8606

Provider Business Practice Location Address
First Line	:	18800 AMAR RD
Second Line	:	B-9
City	:	WALNUT
State	:	CA
Zip	:	91789-4166
Country	:	US
Telephone Number	:	626-839-4696
Fax Number	:	626-965-8606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2008
Last Update Date	:	03/05/2008

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