Provider Demographics
NPI:1255317897
Name:GOULDSBROUGH, LISA (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GOULDSBROUGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:PO BOX 626
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9422
Mailing Address - Country:US
Mailing Address - Phone:207-282-9080
Mailing Address - Fax:207-985-8459
Practice Address - Street 1:3 SHAPE DRIVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043
Practice Address - Country:US
Practice Address - Phone:207-467-8930
Practice Address - Fax:467-985-8459
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-10-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME1395208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME242320099Medicaid
MEE26775Medicare UPIN
ME242320099Medicaid