Provider Demographics
NPI:1124021233
Name:GOSS, BRYAN W (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:GOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-913-5233
Practice Address - Fax:505-913-6466
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2004-02352085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32751575Medicaid
NM32751575Medicaid
NM349421001Medicare PIN