Provider Demographics
NPI:1558332718
Name:GOGULSKI, SCOTT C (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:GOGULSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:025-889-4905
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7926 PRESTON HWY STE 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-964-4357
Practice Address - Fax:502-966-5948
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501860207Q00000X
IN02005420A207Q00000X
TXM7997207Q00000X
KY53331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902650Medicaid
NC5902650Medicaid
W25755Medicare UPIN