1477990182 NPI number — DR. DONALD JEAN GOUDREAU III D.M.D.

Table of content: DR. DONALD JEAN GOUDREAU III D.M.D. (NPI 1477990182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477990182 NPI number — DR. DONALD JEAN GOUDREAU III D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOUDREAU
Provider First Name:
DONALD
Provider Middle Name:
JEAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
D.M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477990182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 RACE ST
Provider Second Line Business Mailing Address:
APT 2E
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-2332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-366-6936
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 N 15TH ST
Provider Second Line Business Practice Location Address:
MAIL STOP MS 467, ROOM 7318
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102-1192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-762-5630
Provider Business Practice Location Address Fax Number:
215-762-8389
Provider Enumeration Date:
06/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  UNKNOWN AT THIS TIME , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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