Provider Demographics
NPI:1134229412
Name:GODDARD, DONALD JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:JOSEPH
Last Name:GODDARD
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 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:
Practice Address - Street 1:143 EXECUTIVE CIR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1180
Practice Address - Country:US
Practice Address - Phone:727-824-0780
Practice Address - Fax:813-514-8891
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062914G207Q00000X
FLME111388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004381401Medicaid
FL004381401Medicaid
F51904Medicare UPIN