Provider Demographics
NPI:1760546212
Name:GOETZ, LEE V (PT)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:V
Last Name:GOETZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 N ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-3348
Mailing Address - Country:US
Mailing Address - Phone:605-725-9900
Mailing Address - Fax:605-725-9902
Practice Address - Street 1:6 N ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-3348
Practice Address - Country:US
Practice Address - Phone:605-725-9900
Practice Address - Fax:605-725-9902
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0435174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0435OtherDAKOTA CARE
SD5830333OtherPALMETTO GBA MEDICARE
4994784OtherBCBS
SD5830333Medicaid
SD5830333Medicaid