Provider Demographics
NPI:1841276326
Name:GODDARD, JANICE JEAN (DO)
Entity type:Individual
Prefix:DR
First Name:JANICE
Middle Name:JEAN
Last Name:GODDARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-3673
Mailing Address - Country:US
Mailing Address - Phone:660-646-0900
Mailing Address - Fax:660-646-7044
Practice Address - Street 1:881 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3673
Practice Address - Country:US
Practice Address - Phone:660-646-0900
Practice Address - Fax:660-646-7044
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7J46207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO15088046OtherBCBS
MO242646701Medicaid
MO242646701Medicaid
MOG220646Medicare ID - Type Unspecified