Provider Demographics
NPI:1033292362
Name:GOULDING, CLARENCE E III (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:E
Last Name:GOULDING
Suffix:III
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 1:200 MED TECH PKWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2278
Mailing Address - Country:US
Mailing Address - Phone:423-915-5033
Mailing Address - Fax:423-952-3777
Practice Address - Street 1:200 MED TECH PKWY
Practice Address - Street 2:SUITE 108
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2278
Practice Address - Country:US
Practice Address - Phone:423-915-5033
Practice Address - Fax:423-952-3777
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15893207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3017571Medicaid
TND90770Medicare UPIN
TN3017571Medicaid
TN103I938622Medicare PIN
TN103I932811Medicare PIN
TN1030I84937Medicare PIN