Provider Demographics
NPI:1558801613
Name:GOEDDE, NATHAN M (OD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:M
Last Name:GOEDDE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-0123
Mailing Address - Country:US
Mailing Address - Phone:419-358-6076
Mailing Address - Fax:419-358-7736
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-1245
Practice Address - Country:US
Practice Address - Phone:419-358-6076
Practice Address - Fax:419-358-7736
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6509152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist