Provider Demographics
NPI:1144322884
Name:GOSSMAN, MELVIN DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:DOUGLAS
Last Name:GOSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M
Other - Middle Name:DOUGLAS
Other - Last Name:GOSSMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1208 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-8014
Mailing Address - Country:US
Mailing Address - Phone:502-225-9488
Mailing Address - Fax:
Practice Address - Street 1:2302 HURSTBOURNE VILLAGE DR
Practice Address - Street 2:700
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1840
Practice Address - Country:US
Practice Address - Phone:502-495-2122
Practice Address - Fax:502-719-0146
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21642207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64216427Medicaid
KY1343401Medicare ID - Type Unspecified
KY64216427Medicaid