Healthcare Provider Details

I. General information

NPI: 1457325896
Provider Name (Legal Business Name): DONALD J GOSSOM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7635 SHELBYVILLE RD
LOUISVILLE KY
40222-5409
US

IV. Provider business mailing address

7635 SHELBYVILLE RD
LOUISVILLE KY
40222-5409
US

V. Phone/Fax

Practice location:
  • Phone: 502-423-8500
  • Fax: 502-339-0571
Mailing address:
  • Phone: 502-423-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1364DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: