Provider Demographics
NPI:1578518007
Name:GOUDEAU, CHRISTIE CHILDRESS (OD)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTIE
Middle Name:CHILDRESS
Last Name:GOUDEAU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 MEDIC AVE
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-3099
Mailing Address - Country:US
Mailing Address - Phone:318-253-9766
Mailing Address - Fax:318-253-8094
Practice Address - Street 1:108 MEDIC AVE
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351
Practice Address - Country:US
Practice Address - Phone:318-253-9766
Practice Address - Fax:318-253-8094
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1372-504T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1948691Medicaid
LA1479918Medicaid
LA4R103C352Medicare ID - Type Unspecified
LA1479918Medicaid
LA5C352Medicare PIN
LA4616000001Medicare NSC