Provider Demographics
NPI:1831197946
Name:GOUDA, M YASSER (MD)
Entity type:Individual
Prefix:MR
First Name:M
Middle Name:YASSER
Last Name:GOUDA
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 1:9523 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3801
Mailing Address - Country:US
Mailing Address - Phone:267-428-6454
Mailing Address - Fax:267-428-6457
Practice Address - Street 1:9523 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3801
Practice Address - Country:US
Practice Address - Phone:267-428-6454
Practice Address - Fax:267-428-6457
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066786L208100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001739115000Medicaid
PA024373H48Medicare PIN
PA001739115000Medicaid
PA024373P8JMedicare PIN