Provider Demographics
NPI:1417230467
Name:GOAN, JOHN R
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:GOAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6710F RITCHIE HWY
Mailing Address - Street 2:SUITE # 412
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-2319
Mailing Address - Country:US
Mailing Address - Phone:617-501-3166
Mailing Address - Fax:410-528-8338
Practice Address - Street 1:48 MASON ST
Practice Address - Street 2:
Practice Address - City:WINCHENDON
Practice Address - State:MA
Practice Address - Zip Code:01475-1531
Practice Address - Country:US
Practice Address - Phone:617-501-3166
Practice Address - Fax:410-528-8338
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45-2829951171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor