Provider Demographics
NPI:1831155563
Name:GOUGER, WILLIAM BREVARD (OD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BREVARD
Last Name:GOUGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 MUELLER RD
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974-2775
Mailing Address - Country:US
Mailing Address - Phone:215-443-9073
Mailing Address - Fax:
Practice Address - Street 1:755 BETHLEHEM PIKE
Practice Address - Street 2:STE 2A
Practice Address - City:MONTGOMERYVILLE
Practice Address - State:PA
Practice Address - Zip Code:18936
Practice Address - Country:US
Practice Address - Phone:215-361-8593
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02147OtherDAVIS VISION
PA501522OtherBLUE CROSS BLUE SHIELD
PA01613276Medicaid
PA501522OtherBLUE CROSS BLUE SHIELD
PA01613276Medicaid