Healthcare Provider Details

I. General information

NPI: 1356320568
Provider Name (Legal Business Name): JEFFREY M GOSSLEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JEFFREY M GOSSLEE MD APMC

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 N ASHLEY RIDGE LOOP STE 400
SHREVEPORT LA
71106-7233
US

IV. Provider business mailing address

PO BOX 65265
SHREVEPORT LA
71136-5265
US

V. Phone/Fax

Practice location:
  • Phone: 318-841-8844
  • Fax: 318-841-8845
Mailing address:
  • Phone: 318-841-8844
  • Fax: 318-841-8845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberM3563
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD026087
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: