Provider Demographics
NPI:1194727396
Name:GODARD, GERALD CRAIG (DC)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:CRAIG
Last Name:GODARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:G.
Other - Middle Name:CRAIG
Other - Last Name:GODARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2812 N NORWALK
Mailing Address - Street 2:SUITE 122
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1148
Mailing Address - Country:US
Mailing Address - Phone:480-844-7900
Mailing Address - Fax:480-699-4281
Practice Address - Street 1:2812 N NORWALK
Practice Address - Street 2:SUITE 122
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-1148
Practice Address - Country:US
Practice Address - Phone:480-844-7900
Practice Address - Fax:480-699-4281
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2012-03-30
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
AZ5851111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ118810Medicare PIN