Basic Information
Provider Information
NPI: 1003297318
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GOZUM
FirstName: VIRGILIO
MiddleName: P
NamePrefix: DR.
NameSuffix:  
Credential: O.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5238 MAIN ST
Address2:  
City: SPRING HILL
State: TN
PostalCode: 371742443
CountryCode: US
TelephoneNumber: 9314891950
FaxNumber:  
Practice Location
Address1: 5238 MAIN ST
Address2:  
City: SPRING HILL
State: TN
PostalCode: 37174
CountryCode: US
TelephoneNumber: 9314891950
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/11/2015
LastUpdateDate: 06/21/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X3245TNY Eye and Vision Services ProvidersOptometrist 
152WC0802X3245TNN Eye and Vision Services ProvidersOptometristCorneal and Contact Management
152WP0200X3245TNN Eye and Vision Services ProvidersOptometristPediatrics
152WS0006X3245TNN Eye and Vision Services ProvidersOptometristSports Vision
152WV0400X3245TNN Eye and Vision Services ProvidersOptometristVision Therapy

No ID Information.


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