Provider Demographics
NPI:1821186925
Name:GOLDSBERRY, JODI A (MD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:A
Last Name:GOLDSBERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 DUFF AVE
Mailing Address - Street 2:PO BOX 3014
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5400
Mailing Address - Country:US
Mailing Address - Phone:515-239-4431
Mailing Address - Fax:515-239-4742
Practice Address - Street 1:1215 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5400
Practice Address - Country:US
Practice Address - Phone:515-239-4431
Practice Address - Fax:515-239-4742
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28187207R00000X
IA39260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC281876Medicaid
SCP00754368OtherRAILROAD MC ID-RSFPN
SCP00648640OtherRAILROAD MEDICARE ID
SC281876Medicaid
SCAA30915551Medicare PIN