Provider Demographics
NPI:1184734501
Name:GOULART, BERNARDO HADDOCK LOBO (MD, MS)
Entity type:Individual
Prefix:DR
First Name:BERNARDO
Middle Name:HADDOCK LOBO
Last Name:GOULART
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-667-2778
Mailing Address - Fax:206-288-1435
Practice Address - Street 1:825 EASTLAKE AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4405
Practice Address - Country:US
Practice Address - Phone:206-667-2778
Practice Address - Fax:206-288-1435
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00048618207RX0202X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0277110OtherL&I
WA1184734501Medicaid
WA8901311Medicare PIN