Provider Demographics
NPI:1306231873
Name:GOTTSCHALK, WILLIAM JORDAN (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JORDAN
Last Name:GOTTSCHALK
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 1:1135 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3037
Mailing Address - Country:US
Mailing Address - Phone:352-394-4035
Mailing Address - Fax:352-394-8585
Practice Address - Street 1:1135 LAKE AVE
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3037
Practice Address - Country:US
Practice Address - Phone:352-394-4035
Practice Address - Fax:352-394-8585
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15396207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025120200Medicaid