Provider Demographics
NPI:1932179314
Name:GOUDREAU, JEFFREY B (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:B
Last Name:GOUDREAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5461 LA SIERRA DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4107
Mailing Address - Country:US
Mailing Address - Phone:214-692-8541
Mailing Address - Fax:214-242-1035
Practice Address - Street 1:5461 LA SIERRA DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4107
Practice Address - Country:US
Practice Address - Phone:214-692-8541
Practice Address - Fax:214-242-1035
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2411207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX043249401Medicaid
TX043249401Medicaid
TX849803Medicare ID - Type Unspecified