Provider Demographics
NPI:1720048150
Name:GOULD, LIESEL L (MD)
Entity Type:Individual
Prefix:
First Name:LIESEL
Middle Name:L
Last Name:GOULD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3019
Mailing Address - Country:US
Mailing Address - Phone:203-248-8888
Mailing Address - Fax:203-248-8889
Practice Address - Street 1:451 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3019
Practice Address - Country:US
Practice Address - Phone:203-248-8888
Practice Address - Fax:203-248-8889
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0353852080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP652646OtherOXFORD
CT035383OtherCONNECTICARE
CT001353838Medicaid
CTOQ1356OtherHEALTHNET