Provider Demographics
NPI:1770560831
Name:GOULDER, STEVEN JAY (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:JAY
Last Name:GOULDER
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 1:500 E OGDEN AVE
Mailing Address - Street 2:200
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-2469
Mailing Address - Country:US
Mailing Address - Phone:630-325-6647
Mailing Address - Fax:630-325-4500
Practice Address - Street 1:500 E OGDEN AVE
Practice Address - Street 2:200
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-2469
Practice Address - Country:US
Practice Address - Phone:630-325-6647
Practice Address - Fax:630-325-4500
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108689207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK09943OtherMEDICARE
IL36108689Medicaid
IL36108689Medicaid
K09942Medicare ID - Type Unspecified
ILIL2486018Medicare PIN