Provider Demographics
NPI:1417990300
Name:GOULD, PERRY M (MD)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:M
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 1:11516 N PORT WASHINGTON RD
Mailing Address - Street 2:STE 202
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-6420
Practice Address - Fax:414-649-5309
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI404872085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32502200Medicaid
WI000701331Medicare ID - Type Unspecified
WI32502200Medicaid
WI000752310Medicare PIN
WI000760310Medicare PIN
001707805Medicare PIN