Provider Demographics
NPI:1831267806
Name:GOUGHNOUR, DALE M (DPM)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:M
Last Name:GOUGHNOUR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-1119
Mailing Address - Country:US
Mailing Address - Phone:814-736-5000
Mailing Address - Fax:814-736-9616
Practice Address - Street 1:220 MAIN ST. STE 100
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946-1119
Practice Address - Country:US
Practice Address - Phone:814-736-5000
Practice Address - Fax:814-736-9616
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004705L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PWGO1304835OtherHIGHMARK
PA304387OtherUPMC
PA043195OtherUMWA
PA01847551Medicaid
PA304387OtherUPMC
PA01847551Medicaid