Provider Demographics
NPI:1275567141
Name:GODDARD, MICHAEL L (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:GODDARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20360 SW BIRCH ST STE 270
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1535
Mailing Address - Country:US
Mailing Address - Phone:949-833-3406
Mailing Address - Fax:949-833-9955
Practice Address - Street 1:20360 SW BIRCH ST STE 270
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1535
Practice Address - Country:US
Practice Address - Phone:949-833-3406
Practice Address - Fax:949-833-9955
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4398213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA06-1710380OtherIRS EIN
CA5621170001Medicare NSC
CAE4398AMedicare ID - Type UnspecifiedPROVIDER NUMBER
CA06-1710380OtherIRS EIN