Provider Demographics
NPI:1174545420
Name:GOULD MULLIGAN, S M (DPM)
Entity type:Individual
Prefix:
First Name:S
Middle Name:M
Last Name:GOULD MULLIGAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:M
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:52 BERLIN RD
Mailing Address - Street 2:SUITE 5000
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3574
Mailing Address - Country:US
Mailing Address - Phone:856-795-1003
Mailing Address - Fax:856-795-5994
Practice Address - Street 1:52 BERLIN RD
Practice Address - Street 2:SUITE 5000
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-3574
Practice Address - Country:US
Practice Address - Phone:856-795-1003
Practice Address - Fax:856-795-5994
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00263000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ01000464100OtherAMERICHOICE
NJ51310OtherAMERIGROUP
6299205OtherGHI
NJ8601801Medicaid
NJ2008280000OtherAMERIHEALTH
NJ7382775OtherCIGNA
IK9329OtherHEALTH NET
NJ1153685OtherHORIZON NJ HEALTH
P2524077OtherOXFORD
P2524077OtherOXFORD
NJ7382775OtherCIGNA
480034878Medicare ID - Type UnspecifiedRAILROAD MEDICARE
U86810Medicare UPIN
NJ480034878Medicare Oscar/Certification