Provider Demographics
NPI:1720241276
Name:GODEAUX, LACEY MATHILDA (MD)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MATHILDA
Last Name:GODEAUX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 INNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-9123
Mailing Address - Country:US
Mailing Address - Phone:985-892-3225
Mailing Address - Fax:
Practice Address - Street 1:1202 S TYLER ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2330
Practice Address - Country:US
Practice Address - Phone:985-892-3225
Practice Address - Fax:985-892-7677
Is Sole Proprietor?:No
Enumeration Date:2008-07-04
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL30817207L00000X
LA205372207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08471706Medicaid
LA2304402Medicaid
LAP01391737Medicare PIN
LA2304402Medicaid