Provider Demographics
NPI:1669534699
Name:GOUVEIA, JACQUELYN (DO)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:GOUVEIA
Suffix:
Gender:F
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8004207RI0200X
CO43339207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194705301Medicaid
NM58850741Medicaid
CO671851OtherANTHEM BCBS
TX194705302Medicaid
CO64573320Medicaid
WY121139100Medicaid
CO7660616OtherAETNA
TX194705302Medicaid
TX8L5708Medicare PIN
COP00273291Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NM58850741Medicaid
CO64573320Medicaid