Provider Demographics
NPI:1407260532
Name:GOLD, JACQUELYN A (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:GOLD
Suffix:
Gender:F
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-441-8084
Practice Address - Fax:508-856-4287
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-260524208000000X
MA2791212084E0001X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110105024AMedicaid