Provider Demographics
NPI:1265431126
Name:GOULD, TODD (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:
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:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1821 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2253
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-0691G207W00000X
WI53432-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
150957CROtherPREFERRED CARE
33311121913800OtherANTHEM BCBS
OH2014680Medicaid
OH180027332OtherPIQUA, RRMED
0800753OtherUNITED HEALTH CARE
OH180028986OtherTROY RRMED
OH180027332OtherPIQUA, RRMED
WI07028Medicare PIN
OH2014680Medicaid
OH0807331Medicare PIN