Provider Demographics
NPI:1063489425
Name:GODDARD, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:GODDARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHIP
Other - Middle Name:
Other - Last Name:GODDARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:600 18TH ST
Mailing Address - Street 2:SUITE 512
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-3231
Mailing Address - Country:US
Mailing Address - Phone:304-424-4574
Mailing Address - Fax:304-424-4429
Practice Address - Street 1:600 18TH ST
Practice Address - Street 2:SUITE 512
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3231
Practice Address - Country:US
Practice Address - Phone:304-424-4574
Practice Address - Fax:304-424-4429
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20468207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002047Medicaid
WV4157311Medicare ID - Type Unspecified
WV3810002047Medicaid