Provider Demographics
NPI:1679627798
Name:GOUDIE, BRETT W (MD)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:W
Last Name:GOUDIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:HASBRO 122
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4612
Mailing Address - Fax:401-793-8831
Practice Address - Street 1:1 HOPPIN ST
Practice Address - Street 2:CORO BUILDING
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4141
Practice Address - Country:US
Practice Address - Phone:401-444-4612
Practice Address - Fax:401-793-8831
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2011-05-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
DEC100080822080P0202X
MDD00680072080P0202X
PAMD4295902080P0202X
RIRI135112080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ109592Medicaid
VA1679627798Medicaid
MD4110510Medicaid
PA101712508Medicaid
PA101712508Medicaid