Provider Demographics
NPI:1730292772
Name:GOULD, THOMAS MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
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 1:4915 BROADWAY
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-3119
Mailing Address - Country:US
Mailing Address - Phone:212-567-9580
Mailing Address - Fax:212-567-9582
Practice Address - Street 1:4915 BROADWAY
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-3119
Practice Address - Country:US
Practice Address - Phone:212-567-9580
Practice Address - Fax:212-567-9582
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129665174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00390670Medicaid
NY340541Medicare ID - Type Unspecified
NY00390670Medicaid