Basic Information
| Provider Information | |||||||||
| NPI: | 1821278912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLOSS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1320 | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251771320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043881724 | ||||||||
| FaxNumber: | 3043881721 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 MORRIS ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043886441 | ||||||||
| FaxNumber: | 3043886445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2007 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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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 | 2084N0600X | 26580 | WV | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 26580 | WV | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 710954 | 05 | AZ | MEDICAID | 00A1076240 | 05 | CA | MEDICAID |