Provider Demographics
NPI:1629008214
Name:GODDARD, JOHN GORDON (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GORDON
Last Name:GODDARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1666 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5714
Mailing Address - Country:US
Mailing Address - Phone:318-212-3750
Mailing Address - Fax:318-212-3755
Practice Address - Street 1:1666 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 105
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5714
Practice Address - Country:US
Practice Address - Phone:318-212-3750
Practice Address - Fax:318-212-3755
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15478R207Q00000X
VA0101057937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1466760Medicaid
LA1466760Medicaid
LA4J376Medicare PIN
LA4J376C731Medicare PIN
LAI25719Medicare UPIN