Provider Demographics
NPI:1780602714
Name:GOULD, RANDALL K (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:K
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:425-317-0279
Mailing Address - Fax:
Practice Address - Street 1:12800 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6642
Practice Address - Country:US
Practice Address - Phone:425-316-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0015759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1208107Medicaid
WAG8857990Medicare PIN
WAA09112Medicare UPIN
WAG8877980Medicare PIN