Provider Demographics
NPI:1437565561
Name:GODER, TAARIQ
Entity Type:Individual
Prefix:
First Name:TAARIQ
Middle Name:
Last Name:GODER
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 1:815 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1080
Mailing Address - Country:US
Mailing Address - Phone:309-672-4977
Mailing Address - Fax:309-672-2580
Practice Address - Street 1:815 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1080
Practice Address - Country:US
Practice Address - Phone:309-672-4977
Practice Address - Fax:309-672-2580
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125065180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine