Healthcare Provider Details

I. General information

NPI: 1942349949
Provider Name (Legal Business Name): MARK T GOULD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 N JEFFERSON ST
JACKSONVILLE FL
32209-6525
US

IV. Provider business mailing address

132 INDIAN HAMMOCK LN
PONTE VEDRA FL
32082-2155
US

V. Phone/Fax

Practice location:
  • Phone: 904-475-6319
  • Fax: 904-475-5809
Mailing address:
  • Phone: 619-865-4915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME131538
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberME131538
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: