Healthcare Provider Details

I. General information

NPI: 1275539801
Provider Name (Legal Business Name): ANDREW RICHARD GOULD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2944 BRECKENRIDGE LN
LOUISVILLE KY
40220-1409
US

IV. Provider business mailing address

PO BOX 950116
LOUISVILLE KY
40295-0116
US

V. Phone/Fax

Practice location:
  • Phone: 502-893-0159
  • Fax: 502-213-3853
Mailing address:
  • Phone: 502-893-0159
  • Fax: 502-213-3853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number32102
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01054760A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number32102
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: