Provider Demographics
NPI:1760439095
Name:GODERWIS, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:GODERWIS
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-212-4700
Mailing Address - Fax:859-212-4761
Practice Address - Street 1:7300 TURFWAY RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1375
Practice Address - Country:US
Practice Address - Phone:859-212-4700
Practice Address - Fax:859-212-4761
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27947208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0723542Medicaid
KY64279474Medicaid
KY64279474Medicaid
OH0723542Medicaid
P00668099Medicare PIN
E90343Medicare UPIN
OH110175532Medicare PIN