Provider Demographics
NPI:1770701104
Name:WILLIAM D. GOUDY D.O., PC
Entity type:Organization
Organization Name:WILLIAM D. GOUDY D.O., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOUDY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:260-927-1982
Mailing Address - Street 1:1306 E 7TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-2537
Mailing Address - Country:US
Mailing Address - Phone:260-927-1982
Mailing Address - Fax:260-927-8380
Practice Address - Street 1:1306 E 7TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2537
Practice Address - Country:US
Practice Address - Phone:260-927-1982
Practice Address - Fax:260-927-8380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000335961OtherANTHEM
INDC0427OtherMEDICARE RAILROAD
IN100103820AMedicaid
IN000000335961OtherANTHEM