Provider Demographics
NPI:1831187723
Name:GOTTFREDSEN, LEA A
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:A
Last Name:GOTTFREDSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HEALTHCARE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03867-4499
Mailing Address - Country:US
Mailing Address - Phone:603-330-3404
Mailing Address - Fax:603-332-8175
Practice Address - Street 1:6 HEALTHCARE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867-4499
Practice Address - Country:US
Practice Address - Phone:603-330-3404
Practice Address - Fax:603-332-8175
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12456207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHU41350OtherANTHEM RAN REFERRAL #
NH2129565OtherCIGNA
NH101115806OtherW/C DEPT OF LABOR PIN
NH04YP08097NH01OtherANTHEM ACES #
NH30223406Medicaid
NH714733OtherHPHC
NH150489OtherTUFTS
3788702OtherAETNA
NH101115806OtherW/C DEPT OF LABOR PIN
NH2129565OtherCIGNA