Provider Demographics
NPI:1093998171
Name:M. DOUGLAS GOSSMAN, MD, PLLC
Entity Type:Organization
Organization Name:M. DOUGLAS GOSSMAN, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:M
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:GOSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-495-2122
Mailing Address - Street 1:2302 HURSTBOURNE VILLAGE DR STE 700
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-1878
Mailing Address - Country:US
Mailing Address - Phone:502-495-2122
Mailing Address - Fax:502-719-0146
Practice Address - Street 1:2302 HURSTBOURNE VILLAGE DR STE 700
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1878
Practice Address - Country:US
Practice Address - Phone:502-495-2122
Practice Address - Fax:502-719-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21642207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty