Healthcare Provider Details

I. General information

NPI: 1831244912
Provider Name (Legal Business Name): WATERFORD MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3560 PONTIAC LAKE RD
WATERFORD MI
48328-2337
US

IV. Provider business mailing address

3560 PONTIAC LAKE RD
WATERFORD MI
48328-2337
US

V. Phone/Fax

Practice location:
  • Phone: 248-674-2259
  • Fax: 248-674-3356
Mailing address:
  • Phone: 248-674-2259
  • Fax: 248-674-3356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL MARTIN GOLD
Title or Position: PRESIDENT
Credential: DO
Phone: 248-674-2259