Provider Demographics
NPI:1467668905
Name:GOSS, JEROME ELDON (MD)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:ELDON
Last Name:GOSS
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:#5 CAMINO DEL SOL
Mailing Address - Street 2:POB 1860
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048
Mailing Address - Country:US
Mailing Address - Phone:505-792-1516
Mailing Address - Fax:
Practice Address - Street 1:#5 CAMINO DEL SOL ST.
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048
Practice Address - Country:US
Practice Address - Phone:505-792-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM68-103207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10918Medicaid
NM2136705Medicare ID - Type Unspecified
NM13801Medicare UPIN