Provider Demographics
NPI:1073569216
Name:GODDARD, JACEY E (DO)
Entity Type:Individual
Prefix:
First Name:JACEY
Middle Name:E
Last Name:GODDARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-7021
Mailing Address - Country:US
Mailing Address - Phone:207-865-6655
Mailing Address - Fax:207-865-6653
Practice Address - Street 1:491 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-7021
Practice Address - Country:US
Practice Address - Phone:207-865-6655
Practice Address - Fax:207-865-6653
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1766207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME0698Medicare ID - Type Unspecified
MEME069803Medicare PIN
MEP01039081Medicare PIN
MEME069802Medicare PIN
MEI10578Medicare UPIN