Healthcare Provider Details

I. General information

NPI: 1083665723
Provider Name (Legal Business Name): TIMOTHY R GOSHEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 WILTON DR SUITE C-2
WILTON MANORS FL
33305-1202
US

IV. Provider business mailing address

2301 WILTON DR SUITE C-2
WILTON MANORS FL
33305-1202
US

V. Phone/Fax

Practice location:
  • Phone: 954-567-5898
  • Fax: 954-567-0395
Mailing address:
  • Phone: 954-567-5898
  • Fax: 954-567-0395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOS8504
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: