Provider Demographics
NPI:1992734669
Name:THE GOSLEN CENTER FOR SKIN WELLNESS, P.A.
Entity type:Organization
Organization Name:THE GOSLEN CENTER FOR SKIN WELLNESS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUNIUS
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:GOSLEN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:704-375-6766
Mailing Address - Street 1:1918 RANDOLPH RD
Mailing Address - Street 2:SUITE550
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1100
Mailing Address - Country:US
Mailing Address - Phone:704-375-6766
Mailing Address - Fax:704-332-6552
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE550
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-375-6766
Practice Address - Fax:704-332-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2325987Medicare ID - Type Unspecified