Provider Demographics
NPI:1093778425
Name:GODDARD, LAURENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:
Last Name:GODDARD
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 1:3917 WEST RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2275
Mailing Address - Country:US
Mailing Address - Phone:505-661-8900
Mailing Address - Fax:505-661-8916
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2275
Practice Address - Country:US
Practice Address - Phone:505-661-8900
Practice Address - Fax:505-661-8916
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 76-177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10728Medicaid
NMC97792Medicare UPIN