Basic Information
| Provider Information | |||||||||
| NPI: | 1578505764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLD | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7920 WYOMING BLVD NE | ||||||||
| Address2: | STE A | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871096020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058216715 | ||||||||
| FaxNumber: | 5058210839 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S COIT RD | ||||||||
| Address2: | STE 40 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750805743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4694618663 | ||||||||
| FaxNumber: | 4694618667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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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 | 237600000X | 51392 | TX | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 80297A | 01 | TX | BCBS IND PROV ID # | OTHER |