Provider Demographics
NPI:1346223955
Name:GOUGH, RICHARD L (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:GOUGH
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 1:610 SOLAREX CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-8624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 W FREDERICK ST
Practice Address - Street 2:
Practice Address - City:WALKERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21793-8230
Practice Address - Country:US
Practice Address - Phone:301-845-6336
Practice Address - Fax:240-578-4478
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0032171207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580505Medicaid
MD926580506Medicaid
MD926580505Medicaid
MDM057Medicare PIN
MDP00242704Medicare PIN
MDCD8143Medicare PIN
MD451LMedicare PIN