Provider Demographics
NPI:1649269051
Name:GOULD, THEODORE ISRAEL (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:ISRAEL
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 1:901 TURTLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1947
Mailing Address - Country:US
Mailing Address - Phone:903-596-3588
Mailing Address - Fax:903-594-2038
Practice Address - Street 1:18118 COUNTY ROAD 344
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:TX
Practice Address - Zip Code:75762
Practice Address - Country:US
Practice Address - Phone:903-596-3588
Practice Address - Fax:903-594-2038
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7469207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137223711Medicaid
TX8C7225Medicare ID - Type Unspecified
TX137223711Medicaid