Provider Demographics
NPI:1912089764
Name:GOSNELL, JOHN L (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
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 1:247 E. 141ST ST
Mailing Address - Street 2:PO BOX 116
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033
Mailing Address - Country:US
Mailing Address - Phone:918-291-1222
Mailing Address - Fax:918-291-1114
Practice Address - Street 1:247 E 141ST ST.
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033
Practice Address - Country:US
Practice Address - Phone:918-291-1222
Practice Address - Fax:918-291-1114
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2217152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100764470AMedicaid
OKOKA103550Medicare PIN