Provider Demographics
NPI:1013940477
Name:GOETZINGER, GREGORY J (OD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:GOETZINGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-1661
Mailing Address - Country:US
Mailing Address - Phone:417-359-0600
Mailing Address - Fax:417-359-0601
Practice Address - Street 1:215 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-1661
Practice Address - Country:US
Practice Address - Phone:417-359-0600
Practice Address - Fax:417-359-0601
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO316731637Medicaid
MO1219660001Medicare NSC
MOU48286Medicare UPIN
MO316731637Medicaid