Basic Information
| Provider Information | |||||||||
| NPI: | 1154373033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOSS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 PRIMERA BLVD STE 1031 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327462124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078348111 | ||||||||
| FaxNumber: | 4077081958 | ||||||||
| Practice Location | |||||||||
| Address1: | 785 PRIMERA BLVD STE 1031 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327462124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078348111 | ||||||||
| FaxNumber: | 4077081958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME46920 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 043254200 | 05 | FL | MEDICAID |