Provider Demographics
NPI:1265482590
Name:GOULD, RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:GOULD
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 1:850 HICKSVILLE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 HICKSVILLE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1300
Practice Address - Country:US
Practice Address - Phone:516-798-0141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180299207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01568661Medicaid
NY37M552Medicare PIN
F97917Medicare UPIN