Provider Demographics
NPI:1215922091
Name:GOULD, JOHN III (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:GOULD
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7430 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2903
Mailing Address - Country:US
Mailing Address - Phone:839-200-7810
Mailing Address - Fax:803-891-7085
Practice Address - Street 1:7430 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2903
Practice Address - Country:US
Practice Address - Phone:839-200-7810
Practice Address - Fax:803-891-7085
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC632207RH0002X
SC00632207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC006326Medicaid
SC006326Medicaid
SCP00139451OtherRAILROAD MEDICARE
SC006326Medicaid
SCH878895038Medicare PIN
SCP00889619OtherMEDICARE RAILROAD