Healthcare Provider Details

I. General information

NPI: 1124021233
Provider Name (Legal Business Name): BRYAN W GOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-5233
  • Fax: 505-913-6466
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number2004-0235
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: