Provider Demographics
NPI:1679576318
Name:GOULD, RAYMOND CLAY (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:CLAY
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 1:1101 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3147
Mailing Address - Country:US
Mailing Address - Phone:504-349-1480
Mailing Address - Fax:504-349-1490
Practice Address - Street 1:1101 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3147
Practice Address - Country:US
Practice Address - Phone:504-349-1480
Practice Address - Fax:504-349-1490
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-26
Last Update Date:2011-06-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-04-26
Provider Licenses
StateLicense IDTaxonomies
LA0190522085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1996033Medicaid
LA5U515CG34Medicare ID - Type Unspecified
LA1996033Medicaid