Provider Demographics
NPI:1881678399
Name:GOOSSENS, JAN BARRY (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:BARRY
Last Name:GOOSSENS
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-716-1000
Mailing Address - Fax:
Practice Address - Street 1:1400 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2455
Practice Address - Country:US
Practice Address - Phone:435-716-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10886108-1205207R00000X
NY222325-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8362OtherRR MEDICARE GROUP
NY110225752OtherRR MEDICARE PIN
PAGU040042OtherMEDICARE GROUP
PA082183N9ZMedicare PIN
NYCC8362OtherRR MEDICARE GROUP
PAP00148933Medicare PIN
PAGU040042OtherMEDICARE GROUP