Basic Information
| Provider Information | |||||||||
| NPI: | 1104837541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 COVENTRY ST | ||||||||
| Address2: | BURGDORF CLINIC - 2ND FLOOR | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061121548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607143690 | ||||||||
| FaxNumber: | 8607148683 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 COVENTRY ST | ||||||||
| Address2: | BURGDORF CLINIC - 2ND FLOOR | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061121548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607143690 | ||||||||
| FaxNumber: | 8607148683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 029114 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001291145CL | 05 | CT | MEDICAID |