Healthcare Provider Details

I. General information

NPI: 1073929550
Provider Name (Legal Business Name): ADITYA R GOUD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2082 MESQUITE AVE STE 100A
LAKE HAVASU CITY AZ
86403-6710
US

IV. Provider business mailing address

PO BOX 3539
LAKE HAVASU CITY AZ
86405-3539
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-2727
  • Fax: 928-453-2828
Mailing address:
  • Phone: 928-453-2727
  • Fax: 928-453-2828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number62285
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number62285
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: