Provider Demographics
NPI:1346294725
Name:GODDARD, ANDREW WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:WILLIAM
Last Name:GODDARD
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 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2210 E ILLINOIS AVE STE 401
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2184
Practice Address - Country:US
Practice Address - Phone:559-320-0580
Practice Address - Fax:559-320-0582
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1326592084P0015X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200355710Medicaid
IN200355710Medicaid
IN116660B8Medicare PIN