Provider Demographics
NPI:1902944739
Name:KENNETH J GOLD MD PA
Entity Type:Organization
Organization Name:KENNETH J GOLD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-343-0913
Mailing Address - Street 1:8000 SOUTH US HWY 1
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-343-0913
Mailing Address - Fax:772-343-0915
Practice Address - Street 1:8000 SOUTH US HWY 1
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-343-0913
Practice Address - Fax:772-343-0915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38984Medicare ID - Type UnspecifiedGROUP