Provider Demographics
NPI:1871631606
Name:GOLD, KENNETH JAY (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAY
Last Name:GOLD
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 1:8000 SOUTH US HWY 1
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-343-0913
Mailing Address - Fax:772-343-0915
Practice Address - Street 1:8000 SOUTH US HWY 1
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-343-0913
Practice Address - Fax:772-343-0915
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00505662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D61010Medicare UPIN
FL04084ZMedicare ID - Type Unspecified