Provider Demographics
NPI:1669752986
Name:GOETZ, JOHN (MED)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GOETZ
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3616
Mailing Address - Country:US
Mailing Address - Phone:405-341-3554
Mailing Address - Fax:
Practice Address - Street 1:1251 N BROADWAY
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3616
Practice Address - Country:US
Practice Address - Phone:405-341-3554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1335101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional