Provider Demographics
NPI:1164045209
Name:GOUGH, STORMIE RAE (DO)
Entity Type:Individual
Prefix:
First Name:STORMIE
Middle Name:RAE
Last Name:GOUGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STORMIE
Other - Middle Name:RAE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 S CEDAR CREST BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 S CEDAR CREST BLVD FL 6
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6202
Practice Address - Country:US
Practice Address - Phone:610-402-7712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-23
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT020219208000000X
PAOS0229972080P0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine