MEDICARE: MR. M YASSER GOUDA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	MD066786L	PA
2	208VP0014X	Interventional Pain Medicine Physician	MD066786L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831197946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. M YASSER GOUDA MD

Provider Business Mailing Address
First Line	:	9523 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-3801
Country	:	US
Telephone Number	:	267-428-6454
Fax Number	:	267-428-6457

Provider Business Practice Location Address
First Line	:	9523 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-3801
Country	:	US
Telephone Number	:	267-428-6454
Fax Number	:	267-428-6457

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	07/13/2016

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