Healthcare Provider Details

I. General information

NPI: 1255317897
Provider Name (Legal Business Name): LISA GOULDSBROUGH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SHAPE DRIVE 2ND FLOOR
KENNEBUNK ME
04043
US

IV. Provider business mailing address

1 MEDICAL CENTER DR PO BOX 626
BIDDEFORD ME
04005-9422
US

V. Phone/Fax

Practice location:
  • Phone: 207-467-8930
  • Fax: 467-985-8459
Mailing address:
  • Phone: 207-282-9080
  • Fax: 207-985-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1395
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier242320099
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: