Provider Demographics
NPI:1588638704
Name:GOULD, STEVEN MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MARK
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 1:5959 LAWNDALE ST
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2921
Mailing Address - Country:US
Mailing Address - Phone:231-845-6261
Mailing Address - Fax:231-843-9171
Practice Address - Street 1:1352 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9318
Practice Address - Country:US
Practice Address - Phone:231-723-8363
Practice Address - Fax:231-398-2680
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004415152W00000X
IA1670152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4956970Medicaid
MI900F410030OtherBCBS OF MICHIGAN
MI4956961Medicaid
MI4956980Medicaid
MIP00349762OtherRAILROAD MEDICARE
MI900E300160OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI4956970Medicaid
MI4956980Medicaid