MEDICARE: THEODORE ISRAEL GOULD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	G7469	TX
2	207Q00000X	Family Medicine Physician	G7469	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649269051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE ISRAEL GOULD MD

Provider Business Mailing Address
First Line	:	901 TURTLE CREEK DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-1947
Country	:	US
Telephone Number	:	903-596-3588
Fax Number	:	903-594-2038

Provider Business Practice Location Address
First Line	:	18118 COUNTY ROAD 344
Second Line	:
City	:	FLINT
State	:	TX
Zip	:	75762
Country	:	US
Telephone Number	:	903-596-3588
Fax Number	:	903-594-2038

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	11/12/2009

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