Provider Demographics
NPI:1205873247
Name:GOUGH, DAVID THOMAS (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:THOMAS
Last Name:GOUGH
Suffix:
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 1:2963 E COPPER POINT DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9055
Mailing Address - Country:US
Mailing Address - Phone:208-322-1730
Mailing Address - Fax:208-322-8996
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1352
Practice Address - Country:US
Practice Address - Phone:208-322-1730
Practice Address - Fax:208-322-1731
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-54207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004311600Medicaid
ID004311600Medicaid
IDD93372Medicare UPIN