Provider Demographics
NPI:1447298443
Name:GOSSMAN, MITCHELL VINCENT (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:VINCENT
Last Name:GOSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 ROOSEVELT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4867
Mailing Address - Country:US
Mailing Address - Phone:320-774-3789
Mailing Address - Fax:320-774-3483
Practice Address - Street 1:628 ROOSEVELT RD STE 101
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4867
Practice Address - Country:US
Practice Address - Phone:320-774-3789
Practice Address - Fax:320-774-3483
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35396207WX0109X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F45321Medicare UPIN