Provider Demographics
NPI:1760440754
Name:GOLOSOW, LORRAINE M (MD)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:M
Last Name:GOLOSOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 CENTRAL AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7649
Mailing Address - Country:US
Mailing Address - Phone:239-939-5233
Mailing Address - Fax:239-939-9225
Practice Address - Street 1:3700 CENTRAL AVE
Practice Address - Street 2:STE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7649
Practice Address - Country:US
Practice Address - Phone:239-939-5233
Practice Address - Fax:239-939-9225
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME760662086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG75475Medicare UPIN
FL43704ZMedicare ID - Type UnspecifiedMEDICARE