Basic Information
| Provider Information | |||||||||
| NPI: | 1952310054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORTY | ||||||||
| FirstName: | SRI | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 ROYALTY DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098659889 | ||||||||
| FaxNumber: | 9098659724 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 ROYALTY DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098659890 | ||||||||
| FaxNumber: | 9098659697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | A73742 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | A73742 | 01 | OTHER | OTHER | 00A737220 | 05 | CA | MEDICAID |