Provider Demographics
NPI:1083665723
Name:GOSHEN, TIMOTHY R (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
Last Name:GOSHEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 WILTON DR
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1202
Mailing Address - Country:US
Mailing Address - Phone:954-567-5898
Mailing Address - Fax:954-567-0395
Practice Address - Street 1:2301 WILTON DR
Practice Address - Street 2:SUITE C-2
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1202
Practice Address - Country:US
Practice Address - Phone:954-567-5898
Practice Address - Fax:954-567-0395
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8504174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266516600Medicaid
FLA66622Medicare UPIN
FL266516600Medicaid