Provider Demographics
NPI:1598709826
Name:GOSE, FRED DEXTER (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:DEXTER
Last Name:GOSE
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 1:1875 MOUNTAIN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1015
Mailing Address - Country:US
Mailing Address - Phone:770-939-0778
Mailing Address - Fax:770-938-6760
Practice Address - Street 1:1875 MOUNTAIN CREEK DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-1015
Practice Address - Country:US
Practice Address - Phone:770-939-0778
Practice Address - Fax:770-938-6760
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28557207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0003293480Medicaid
GA941025OtherBLUE CROSS
GAQ45445Medicare UPIN
GA0003293480Medicaid