Provider Demographics
NPI:1285659607
Name:GOULD, KEITH RANDALL (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:RANDALL
Last Name:GOULD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:301 TYSON AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4544
Practice Address - Country:US
Practice Address - Phone:731-642-1220
Practice Address - Fax:731-642-1220
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6352207P00000X, 208100000X
TN2660207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261972500Medicaid
FLF35027Medicare UPIN
FL261972500Medicaid