Provider Demographics
NPI:1164657839
Name:GOULD, MICHAEL DEREK
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEREK
Last Name:GOULD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 RIDGE VALE CIR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-5649
Mailing Address - Country:US
Mailing Address - Phone:813-478-5711
Mailing Address - Fax:
Practice Address - Street 1:6930 OSPREY RIDGE DR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-3915
Practice Address - Country:US
Practice Address - Phone:813-478-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-23
Last Update Date:2009-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47607172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist