Provider Demographics
NPI:1861451031
Name:GOSSARD, TERESA A (OD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:GOSSARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 FAIR LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-3434
Mailing Address - Country:US
Mailing Address - Phone:513-221-5274
Mailing Address - Fax:513-961-5100
Practice Address - Street 1:2859 BOUDINOT AVE
Practice Address - Street 2:STE 301
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-1606
Practice Address - Country:US
Practice Address - Phone:513-661-3566
Practice Address - Fax:513-661-6469
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4742 T1546152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2107393Medicaid
OH410039511OtherRAILROAD MEDICARE
OH0872881Medicare PIN
OH0872886Medicare PIN
OH0872883Medicare PIN
OHU75009Medicare UPIN
OH410039511OtherRAILROAD MEDICARE
OH0872885Medicare PIN
OH0872882Medicare PIN