Basic Information
| Provider Information | |||||||||
| NPI: | 1881632842 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTFURCHT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BARRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1430 | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910171430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262566010 | ||||||||
| FaxNumber: | 6262566070 | ||||||||
| Practice Location | |||||||||
| Address1: | 11026 VALLEY MALL | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917312617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264435938 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C38243 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00C382430 | 05 | CA | MEDICAID |