Provider Demographics
NPI:1235232646
Name:GOBLE, EDWIN MARLOWE (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:MARLOWE
Last Name:GOBLE
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 1:2380 N 400 E
Mailing Address - Street 2:SUITE G
Mailing Address - City:N LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-752-4665
Mailing Address - Fax:435-752-4662
Practice Address - Street 1:274 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3915
Practice Address - Country:US
Practice Address - Phone:435-753-1600
Practice Address - Fax:435-753-9521
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1215111205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012439Medicare ID - Type Unspecified
C63454Medicare UPIN
UT000012439Medicare PIN