Provider Demographics
NPI:1619012804
Name:JEFFREY D GOSS DPM INC.
Entity Type:Organization
Organization Name:JEFFREY D GOSS DPM INC.
Other - Org Name:ENCINO PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-995-3039
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:STE 630
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-995-3039
Mailing Address - Fax:818-995-3368
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:STE 630
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-995-3039
Practice Address - Fax:818-995-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2510261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E25100Medicaid
CAW21713OtherMEDICARE PTAN
CAW21713OtherMEDICARE PTAN
CA5419080001Medicare NSC
CAT11366Medicare UPIN