Provider Demographics
NPI:1487044517
Name:GODDARD, GILLIAN ROSE (MD)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:ROSE
Last Name:GODDARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 CRANSTON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1848
Mailing Address - Country:US
Mailing Address - Phone:972-900-2356
Mailing Address - Fax:
Practice Address - Street 1:38 CRANSTON ST APT 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-1848
Practice Address - Country:US
Practice Address - Phone:972-900-2356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA285521208600000X
OH35.134478208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery