Provider Demographics
NPI:1083691471
Name:GOURIEUX, ERIC D (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:D
Last Name:GOURIEUX
Suffix:
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7926 PRESTON HWY STE 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-964-4357
Practice Address - Fax:502-966-5948
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038628207Q00000X
KYTP297207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100432980Medicaid
F18961Medicare UPIN
080192441OtherRAILROAD MEDICARE
IN194730DMedicare PIN
043679294004OtherTRICARE
237380OtherHEALTHLINK
F18961Medicare UPIN
043679294002OtherUNICARE
IN100432980Medicaid
04367929416OtherDONLEY & CO
045670OtherHEALTH ALLIANCE