Provider Demographics
NPI:1518232149
Name:GOULD, SOLOMON M (OD)
Entity Type:Individual
Prefix:
First Name:SOLOMON
Middle Name:M
Last Name:GOULD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 BURNS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4906
Mailing Address - Country:US
Mailing Address - Phone:651-739-5173
Mailing Address - Fax:651-739-8907
Practice Address - Street 1:1995 BURNS AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4906
Practice Address - Country:US
Practice Address - Phone:651-739-5173
Practice Address - Fax:651-739-8907
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0000000152W00000X
MN3415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT030-0086043OtherVERMONT LICENSE
MN1518232149OtherNPI TYE I
MN3415OtherMN LICENSE