Provider Demographics
NPI:1811063142
Name:GOUGH, BEVERLY ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:ANNE
Last Name:GOUGH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:1950 OLD GALLOWS RD
Practice Address - Street 2:SUITE 520
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3990
Practice Address - Country:US
Practice Address - Phone:703-847-8899
Practice Address - Fax:703-991-0514
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-680 TA-388152W00000X
NC1351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09311OtherBCBS OF NC
NCDE7256OtherRAILROAD MEDICARE GROUP
AL00343OtherBLUE CROSS BLUE SHIELD
NC8909311Medicaid
AL00343OtherBLUE CROSS BLUE SHIELD
NC2467126GMedicare PIN
NC2467126HMedicare PIN
NC2467126EMedicare PIN
NCDE7256OtherRAILROAD MEDICARE GROUP
ALT88022Medicare UPIN
AL000046878Medicare ID - Type Unspecified
NC8909311Medicaid
NC2467126BMedicare PIN
NC2467126FMedicare PIN