Basic Information
| Provider Information | |||||||||
| NPI: | 1538120167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOUDREAU | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 233 | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074597195 | ||||||||
| FaxNumber: | 2074597609 | ||||||||
| Practice Location | |||||||||
| Address1: | 25A JUNE ST STE 16 | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040732615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073241488 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 5101013602 | ME | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208600000X | DO1751 | ME | N | Allopathic & Osteopathic Physicians | Surgery | 207X00000X | DO1751 | ME | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 261390099 | 05 | ME | MEDICAID |