Provider Demographics
NPI:1619991775
Name:GOCO, ISMAEL ROLDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ISMAEL
Middle Name:ROLDAN
Last Name:GOCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ISMAEL
Other - Middle Name:
Other - Last Name:GOCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:790 HIGHLAND OAKS DR.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-768-4710
Mailing Address - Fax:336-659-9845
Practice Address - Street 1:790 HIGHLAND OAKS DR.
Practice Address - Street 2:SUITE 200
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-4710
Practice Address - Fax:336-659-9845
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13457174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8936055Medicaid
NC36055OtherBCBS OF NC
NC206668AMedicare ID - Type Unspecified
NCC84090Medicare UPIN