Provider Demographics
NPI:1306841820
Name:GOEDDE, TIMOTHY A (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:GOEDDE
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7430 N SHADELAND AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2036
Practice Address - Country:US
Practice Address - Phone:317-288-2456
Practice Address - Fax:317-288-2461
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039996A208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100441710Medicaid
INP01347706OtherMEDICARE RR PTAN
IN000000775120OtherANTHEM
IN4258887OtherAETNA
INE87212Medicare UPIN
INP01347706OtherMEDICARE RR PTAN
IN100441710Medicaid