Healthcare Provider Details

I. General information

NPI: 1427292895
Provider Name (Legal Business Name): LIONEL JOHN GOTTSCHALK IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4386 TRAIL BOSS DR
CASTLE ROCK CO
80104-7512
US

IV. Provider business mailing address

4386 TRAIL BOSS DR
CASTLE ROCK CO
80104-7512
US

V. Phone/Fax

Practice location:
  • Phone: 719-209-8630
  • Fax: 719-473-3553
Mailing address:
  • Phone: 719-209-8630
  • Fax: 719-473-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberDR. 0055408
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: