Provider Demographics
NPI:1871719955
Name:GOSNELL, DAVID P (OPTICIAN)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:GOSNELL
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:104 SIMPSON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4413
Practice Address - Country:US
Practice Address - Phone:864-522-3900
Practice Address - Fax:864-522-3909
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC428156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDVO428Medicaid