1104481787 NPI number — DR. OLIVIA L GOULD DO

Table of content: DR. OLIVIA L GOULD DO (NPI 1104481787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104481787 NPI number — DR. OLIVIA L GOULD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOULD
Provider First Name:
OLIVIA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104481787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37174
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-3174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-423-5699
Provider Business Mailing Address Fax Number:
571-423-5698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 GALLOWS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22042-3307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-776-4001
Provider Business Practice Location Address Fax Number:
703-776-7113
Provider Enumeration Date:
05/08/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 0101276067 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0101276067 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0116033131 . This is a "MEDICAL TRAINING LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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