Provider Demographics
NPI:1245221886
Name:GOSSOM, JOHN BURK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BURK
Last Name:GOSSOM
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:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-1550
Mailing Address - Country:US
Mailing Address - Phone:360-378-1338
Mailing Address - Fax:360-378-1830
Practice Address - Street 1:689 AIRPORT CENTER DR
Practice Address - Street 2:STE B
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250
Practice Address - Country:US
Practice Address - Phone:360-378-1338
Practice Address - Fax:360-378-1830
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018422207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5877GOOtherREGENCE BLUE SHIELD
912109329OtherCIGNA BEECH ST
912109329OtherCOMMUNITY HEALTHPLAN OF W
0152514OtherLABOR AND INDUSTRIES
5403470OtherCCN
912109329OtherTRIWEST
912109329OtherTAX ID
912109329OtherPREMERA BLUE CROSS
361929500OtherUS DEPT OF LABOR
532300001OtherGROUP HEALTH
8101404OtherDSHS
MD00018422OtherLICENSE NUMBER
98250A003OtherTRIWEST
8937843OtherCRIME VICTIMS
912109329OtherFIRST CHOICE
912109329OtherTRIWEST
AB23629Medicare ID - Type Unspecified