Healthcare Provider Details

I. General information

NPI: 1013273861
Provider Name (Legal Business Name): ANDREA GOUGH-GOLDMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 SE 82ND AVE
PORTLAND OR
97266-2902
US

IV. Provider business mailing address

3580 SE 82ND AVE
PORTLAND OR
97266-2902
US

V. Phone/Fax

Practice location:
  • Phone: 971-339-9240
  • Fax:
Mailing address:
  • Phone: 719-339-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD172073
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: