Provider Demographics
NPI:1023292166
Name:GOSNELL, DANIEL BRUCE (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:BRUCE
Last Name:GOSNELL
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 AUGUSTA STREET
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605
Mailing Address - Country:US
Mailing Address - Phone:864-233-4148
Mailing Address - Fax:864-233-3620
Practice Address - Street 1:1946 AUGUSTA STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-233-4148
Practice Address - Fax:864-233-3620
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC203156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDV0203Medicaid
SCDV0203Medicaid