Basic Information
| Provider Information | |||||||||
| NPI: | 1649269051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | ISRAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 TURTLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035963588 | ||||||||
| FaxNumber: | 9035942038 | ||||||||
| Practice Location | |||||||||
| Address1: | 18118 COUNTY ROAD 344 | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035963588 | ||||||||
| FaxNumber: | 9035942038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 11/12/2009 | ||||||||
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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 | 207P00000X | G7469 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | G7469 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 137223711 | 05 | TX | MEDICAID |