Provider Demographics
NPI:1952762965
Name:GOUKASSIAN, ILONA DAVIDOVNA (DO)
Entity Type:Individual
Prefix:DR
First Name:ILONA
Middle Name:DAVIDOVNA
Last Name:GOUKASSIAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-713-7251
Mailing Address - Fax:336-713-0306
Practice Address - Street 1:4515 PREMIER DR STE 401
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8356
Practice Address - Country:US
Practice Address - Phone:336-802-2240
Practice Address - Fax:336-802-2243
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI0000207R00000X
NC247648390200000X
NC2021-01152207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program