Healthcare Provider Details

I. General information

NPI: 1144285859
Provider Name (Legal Business Name): WALTER J GOULA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 CORLISS ST STE B
PROVIDENCE RI
02904-2602
US

IV. Provider business mailing address

180 CORLISS ST STE B
PROVIDENCE RI
02904-2602
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8400
  • Fax: 401-793-8402
Mailing address:
  • Phone: 401-793-8400
  • Fax: 401-793-8402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number77245
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD09442
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: