Healthcare Provider Details

I. General information

NPI: 1295784627
Provider Name (Legal Business Name): JUDITH A. GOULD R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DAVID GRANT MEDICAL CENTER
TRAVIS AFB CA
94535-1800
US

IV. Provider business mailing address

422 PICO WAY
SACRAMENTO CA
95819-2926
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7300
  • Fax:
Mailing address:
  • Phone: 916-739-6435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number718204
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: