Provider Demographics
NPI:1487688685
Name:GOURDE, THERESA (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GOURDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10623 S REDWOOD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2481
Mailing Address - Country:US
Mailing Address - Phone:801-302-0899
Mailing Address - Fax:801-302-0892
Practice Address - Street 1:10623 S REDWOOD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-2481
Practice Address - Country:US
Practice Address - Phone:801-302-0899
Practice Address - Fax:801-302-0892
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111485-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT111485-1205OtherMEDICAL LICENSE
UT1447360383Medicaid
UT1982871828Medicaid
UT000060282Medicare PIN
P00731891Medicare PIN
UTF64965Medicare UPIN
UT1447360383Medicaid
UT000066664Medicare PIN