Provider Demographics
NPI:1477563096
Name:GOUDREAU, JOHN LESTER (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LESTER
Last Name:GOUDREAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD # A201
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:804 SERVICE RD # A217
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7015
Practice Address - Country:US
Practice Address - Phone:517-353-8122
Practice Address - Fax:517-432-3713
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010127512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1477563096Medicaid
MI4318494Medicaid
MIG72450Medicare UPIN
MI4318494Medicaid