Healthcare Provider Details

I. General information

NPI: 1093276966
Provider Name (Legal Business Name): MICA GOULBOURNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 CALHOUN ST
NEW ORLEANS LA
70118-5962
US

IV. Provider business mailing address

1100 POYDRAS ST
NEW ORLEANS LA
70163-1101
US

V. Phone/Fax

Practice location:
  • Phone: 504-896-9827
  • Fax:
Mailing address:
  • Phone: 504-527-9952
  • Fax: 504-527-9950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License Number346102
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: