Basic Information
| Provider Information | |||||||||
| NPI: | 1619991775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOCO | ||||||||
| FirstName: | ISMAEL | ||||||||
| MiddleName: | ROLDAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOCO | ||||||||
| OtherFirstName: | ISMAEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 HIGHLAND OAKS DR. | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367684710 | ||||||||
| FaxNumber: | 3366599845 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 HIGHLAND OAKS DR. | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367684710 | ||||||||
| FaxNumber: | 3366599845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 13457 | NC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8936055 | 05 | NC | MEDICAID | 36055 | 01 | NC | BCBS OF NC | OTHER |