Provider Demographics
NPI:1992737506
Name:GOSS, LARRY R (DPM)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:R
Last Name:GOSS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 E ALLEGHENY AVE
Mailing Address - Street 2:PO BOX 26848
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-3832
Mailing Address - Country:US
Mailing Address - Phone:215-425-3700
Mailing Address - Fax:
Practice Address - Street 1:2075 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-3832
Practice Address - Country:US
Practice Address - Phone:215-425-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-004111-L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016484690002Medicaid
PAU66247Medicare UPIN
PAGO908823Medicare ID - Type Unspecified