Provider Demographics
NPI:1417957085
Name:GOULART, JOHN W (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:GOULART
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:580-234-2289
Mailing Address - Fax:580-249-4350
Practice Address - Street 1:620 S MADISON ST
Practice Address - Street 2:SUITE 108
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-7270
Practice Address - Country:US
Practice Address - Phone:580-234-2289
Practice Address - Fax:580-249-4350
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4191208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200032320AMedicaid
OKP00155199OtherRR MEDICARE
OK200032320BOtherMEDICAID OSU AJ
OK242419800Medicare PIN
H83098Medicare UPIN