Provider Demographics
NPI:1851355804
Name:GOUGH, ADAM C (DPM)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:C
Last Name:GOUGH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7287
Mailing Address - Country:US
Mailing Address - Phone:575-538-2981
Mailing Address - Fax:575-388-3373
Practice Address - Street 1:1600 E 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7287
Practice Address - Country:US
Practice Address - Phone:575-538-2981
Practice Address - Fax:575-388-3373
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM275213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG0018Medicaid
NMG0018Medicaid
NM4927888867Medicare PIN