Provider Demographics
NPI:1184653719
Name:GODDARD, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
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 1:151 W GALBRAITH RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45216-1015
Mailing Address - Country:US
Mailing Address - Phone:513-416-2484
Mailing Address - Fax:513-418-2698
Practice Address - Street 1:151 W GALBRAITH RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45216-1015
Practice Address - Country:US
Practice Address - Phone:513-948-2707
Practice Address - Fax:513-948-2698
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-053722208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000012876OtherANTHEM
OH0629743Medicaid
IN100351670Medicaid
KY64787427Medicaid
OH0629743Medicaid
A16514Medicare UPIN