Provider Demographics
NPI:1619076403
Name:GOTTSCHALL, DANIEL SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:SCOTT
Last Name:GOTTSCHALL
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 1:4749 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-374-5013
Mailing Address - Fax:203-374-2377
Practice Address - Street 1:4797 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-374-5013
Practice Address - Fax:203-374-2377
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035997207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0013S9977Medicaid
G47549Medicare UPIN
CT0013S9977Medicaid