Provider Demographics
NPI:1275032492
Name:GODDARD, DAVID ALAN (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
Last Name:GODDARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:BOX 112727
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3003
Mailing Address - Country:US
Mailing Address - Phone:352-273-7002
Mailing Address - Fax:352-273-7293
Practice Address - Street 1:3450 HULL RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-4144
Practice Address - Country:US
Practice Address - Phone:352-273-7002
Practice Address - Fax:352-273-7293
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2020-03-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9110861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100883400Medicaid