Provider Demographics
NPI:1457325896
Name:GOSSOM, DONALD J (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:GOSSOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7635 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5409
Mailing Address - Country:US
Mailing Address - Phone:502-423-8500
Mailing Address - Fax:
Practice Address - Street 1:7635 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5409
Practice Address - Country:US
Practice Address - Phone:502-423-8500
Practice Address - Fax:502-339-0571
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1364DT152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77013647Medicaid
KY000000047535OtherANTHEM BCBS
5420222OtherAETNA
0191960001Medicare NSC
KY0660202Medicare PIN
410039861Medicare PIN
U63653Medicare UPIN