Provider Demographics
NPI:1740257302
Name:GOULD, MARK DAVID (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:GOULD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:32730 WALKER RD
Mailing Address - Street 2:SUITE I-3
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-4100
Mailing Address - Country:US
Mailing Address - Phone:440-933-4021
Mailing Address - Fax:440-933-7132
Practice Address - Street 1:32730 WALKER RD
Practice Address - Street 2:SUITE I-3
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-4100
Practice Address - Country:US
Practice Address - Phone:440-933-4021
Practice Address - Fax:440-933-7132
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.002416213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH480004004OtherRAILROAD MEDICARE
GO0597392Medicare PIN
OHT80680Medicare UPIN
OH0603440001Medicare NSC