Provider Demographics
NPI:1356320568
Name:GOSSLEE, JEFFREY M (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:GOSSLEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:M
Other - Last Name:GOSSLEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD APMC
Mailing Address - Street 1:PO BOX 65265
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71136-5265
Mailing Address - Country:US
Mailing Address - Phone:318-841-8844
Mailing Address - Fax:318-841-8845
Practice Address - Street 1:725 N ASHLEY RIDGE LOOP STE 400
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7233
Practice Address - Country:US
Practice Address - Phone:318-841-8844
Practice Address - Fax:318-841-8845
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3563207WX0107X, 207WX0107X
LAMD026087207WX0107X, 207WX0107X, 207W00000X
LA26087207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1568851053OtherGROUP NPI
LA1053201Medicaid
LA1356320568OtherIND NPI
TX179865401Medicaid
TX179865404Medicaid
TX179865405Medicaid
TX179865402Medicaid
TX8G5214Medicare PIN
TX179865401Medicaid
TX8G5218Medicare PIN
TX8G5217Medicare PIN
TX8G5213Medicare PIN
TX179865402Medicaid
TX8G5216Medicare PIN
TX179865406Medicaid
LA5CE23Medicare PIN
LA4N297CE23Medicare PIN
TX8G5215Medicare PIN