Healthcare Provider Details

I. General information

NPI: 1467623421
Provider Name (Legal Business Name): GOUTHAM K GOSU AU.D, CCC-A, F-AAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 COLONY RD STE B
CHARLOTTE NC
28211-5022
US

IV. Provider business mailing address

3900 COLONY RD STE B
CHARLOTTE NC
28211-5022
US

V. Phone/Fax

Practice location:
  • Phone: 704-944-4283
  • Fax: 980-819-7817
Mailing address:
  • Phone: 704-944-4283
  • Fax: 980-819-7817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number11105
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number11105
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: