Provider Demographics
NPI:1184630352
Name:GOULD, RANDY BRUCE (DO)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:BRUCE
Last Name:GOULD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171A E 65TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6607
Mailing Address - Country:US
Mailing Address - Phone:212-223-1025
Mailing Address - Fax:212-750-3201
Practice Address - Street 1:171A E 65TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6607
Practice Address - Country:US
Practice Address - Phone:212-223-1025
Practice Address - Fax:212-750-3201
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7937207RC0000X
NY204733207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266497600Medicaid
H46168Medicare UPIN
FLE6046Medicare PIN