Basic Information
| Provider Information | |||||||||
| NPI: | 1649470469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOSS | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25180 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972980180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929108 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Practice Location | |||||||||
| Address1: | 9205 SW BARNES RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929108 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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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 | 2085R0202X | N3688 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 175201 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 323504601 | 05 | TX | MEDICAID |