Provider Demographics
NPI:1457915886
Name:GODDARD, ANGELA (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GODDARD
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 1:5820 WILSHIRE BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5820 WILSHIRE BLVD STE 203
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4587
Practice Address - Country:US
Practice Address - Phone:310-494-6678
Practice Address - Fax:309-328-3823
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA179227174400000X, 2084P0800X, 174400000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program