Provider Demographics
NPI:1679652689
Name:GOTH, ERIC J (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:GOTH
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 1:340 MIDLAND RD STE 120
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2339
Mailing Address - Country:US
Mailing Address - Phone:608-743-9313
Mailing Address - Fax:608-743-9318
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511
Practice Address - Country:US
Practice Address - Phone:608-362-7888
Practice Address - Fax:608-362-8470
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1299672085R0202X
WI51248-0202085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679652689Medicaid