Healthcare Provider Details

I. General information

NPI: 1962733899
Provider Name (Legal Business Name): BRUCE JAY GOULD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 BUTTONWOOD ST APT 1020
PHILADELPHIA PA
19130-3945
US

IV. Provider business mailing address

1801 BUTTONWOOD ST APT 1020
PHILADELPHIA PA
19130-3945
US

V. Phone/Fax

Practice location:
  • Phone: 215-253-3001
  • Fax:
Mailing address:
  • Phone: 215-253-3001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberMD026686L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: