Provider Demographics
NPI:1912432550
Name:GOFORTH, JOHN BRADLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 N LIBERTY ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8708
Mailing Address - Country:US
Mailing Address - Phone:208-302-1200
Mailing Address - Fax:
Practice Address - Street 1:1072 N LIBERTY STREET
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8706
Practice Address - Country:US
Practice Address - Phone:208-302-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1517207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty