Healthcare Provider Details

I. General information

NPI: 1871719955
Provider Name (Legal Business Name): DAVID P GOSNELL OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SIMPSON ST
GREENVILLE SC
29605-4413
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-522-3900
  • Fax: 864-522-3909
Mailing address:
  • Phone: 864-522-8603
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number428
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: