Provider Demographics
NPI:1780771584
Name:GOEDERT, STEVEN LEE (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:LEE
Last Name:GOEDERT
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 1:1465 VICTOR AVE
Mailing Address - Street 2:STE. D
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003
Mailing Address - Country:US
Mailing Address - Phone:530-722-0200
Mailing Address - Fax:530-722-0210
Practice Address - Street 1:1465 VICTOR AVE
Practice Address - Street 2:STE. D
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003
Practice Address - Country:US
Practice Address - Phone:530-722-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5674T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10078Medicare UPIN
CA5628170001Medicare NSC
CASD0056740Medicare PIN