Healthcare Provider Details

I. General information

NPI: 1093826968
Provider Name (Legal Business Name): JOSHUA J. GOODEN, OPTOMETRIST, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 ALBERT AVE.
SCOTT CITY KS
67871-1216
US

IV. Provider business mailing address

PO BOX 712
SCOTT CITY KS
67871-0712
US

V. Phone/Fax

Practice location:
  • Phone: 620-872-0040
  • Fax: 620-872-0041
Mailing address:
  • Phone: 620-872-0040
  • Fax: 620-872-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1528
License Number StateKS

VIII. Authorized Official

Name: DR. JOSHUA J. GOODEN
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 620-872-0040