Basic Information
| Provider Information | |||||||||
| NPI: | 1538259262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | VIRTUA AND DUPONT CHILDRENS HEALTH PROGRAM | ||||||||
| Address2: | 1000 WHITE HORSE ROAD SUITE 204 | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563098508 | ||||||||
| FaxNumber: | 8563098556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 04/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NR05622800 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | NR05622800 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 22616 | 05 | NJ | MEDICAID | 4040228 | 05 | MD | MEDICAID |