Provider Demographics
NPI:1962458612
Name:GOSNELL, JOHN A (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:GOSNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5404
Mailing Address - Country:US
Mailing Address - Phone:308-534-2000
Mailing Address - Fax:308-534-2001
Practice Address - Street 1:111 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5404
Practice Address - Country:US
Practice Address - Phone:308-537-3390
Practice Address - Fax:308-537-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1166332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10024975800Medicaid
NE06754OtherBLUE CROSS BLUE SHIELD NE
240481OtherMIDLANDS CHOICE
NE10024975800Medicaid
NE4978230001Medicare NSC
P00121722Medicare PIN
NE276388Medicare PIN
NEU76837Medicare UPIN