Provider Demographics
NPI:1275062432
Name:GOUGE, TYLER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:GOUGE
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 1:331 HOSPITAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-9251
Mailing Address - Country:US
Mailing Address - Phone:417-533-6560
Mailing Address - Fax:
Practice Address - Street 1:701 S NEW BALLAS RD STE 510
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8726
Practice Address - Country:US
Practice Address - Phone:314-251-6710
Practice Address - Fax:314-251-6712
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020020734207QS0010X, 207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine