Basic Information
| Provider Information | |||||||||
| NPI: | 1942349949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 117345 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463465 | ||||||||
| FaxNumber: | 9048586489 | ||||||||
| Practice Location | |||||||||
| Address1: | 1577 ROBERTS DR STE 225 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042411204 | ||||||||
| FaxNumber: | 9042417331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME131538 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | ME131538 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
No ID Information.