Provider Demographics
NPI:1639270630
Name:GOSNELL, CHAD ERIC (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:ERIC
Last Name:GOSNELL
Suffix:
Gender:M
Credentials:OD
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Other - Credentials:
Mailing Address - Street 1:4500 STUART ST; MONCRIEF ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:ATTN: MCXL-PQ (CREDENTIALS)
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5720
Mailing Address - Country:US
Mailing Address - Phone:803-751-2618
Mailing Address - Fax:803-751-2689
Practice Address - Street 1:4500 STUART STREET
Practice Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL/CREDENTIALS
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-5720
Practice Address - Country:US
Practice Address - Phone:803-751-2618
Practice Address - Fax:803-751-2689
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA4003152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVAD 000Medicare UPIN