Provider Demographics
NPI:1710094578
Name:GOULKO, OLGA (MD)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:GOULKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 CENTER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5810
Mailing Address - Country:US
Mailing Address - Phone:201-461-5655
Mailing Address - Fax:201-461-1181
Practice Address - Street 1:2125 CENTER AVE STE 200
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5810
Practice Address - Country:US
Practice Address - Phone:201-461-5655
Practice Address - Fax:201-461-1181
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA065361207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7750102Medicare ID - Type Unspecified
NJ016093Medicare ID - Type Unspecified
G79516Medicare UPIN