Provider Demographics
NPI:1629644489
Name:GOTTSCHALK, AUSTIN (DO)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:GOTTSCHALK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 E SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-5711
Mailing Address - Country:US
Mailing Address - Phone:801-671-6294
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVENUE BLDG. 1408
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:575-904-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXUNKNOWN208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery