Basic Information
| Provider Information | |||||||||
| NPI: | 1316923444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORECKI | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1690 | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463521690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262312 | ||||||||
| FaxNumber: | 2193262584 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 LINCOLNWAY | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193627506 | ||||||||
| FaxNumber: | 2193621459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036 070820 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 01038951 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 10016541A | 05 | IN | MEDICAID | 000000514107 | 01 | IN | ANTHEM, BCBS | OTHER |