Provider Demographics
NPI:1326033754
Name:GODDARD, MINI B (MD)
Entity Type:Individual
Prefix:DR
First Name:MINI
Middle Name:B
Last Name:GODDARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MINI
Other - Middle Name:B
Other - Last Name:GODDARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:401 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4255
Mailing Address - Country:US
Mailing Address - Phone:312-635-0973
Mailing Address - Fax:
Practice Address - Street 1:401 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4255
Practice Address - Country:US
Practice Address - Phone:312-635-0973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067560208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2863512Medicaid
MIG26439Medicare UPIN
OHGO4221621Medicare PIN