Provider Demographics
NPI:1912902792
Name:GOSS, JEFFREY D (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:GOSS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:STE 630
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4318
Mailing Address - Country:US
Mailing Address - Phone:818-995-3039
Mailing Address - Fax:818-995-3368
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:STE 630
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4318
Practice Address - Country:US
Practice Address - Phone:818-995-3039
Practice Address - Fax:818-995-3368
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2510213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21713OtherMEDICARE PTAN
CA000E25100Medicaid
CAT11366Medicare UPIN
CA5419080001Medicare NSC
CAE2510Medicare PIN