Provider Demographics
NPI:1285969659
Name:GOEDDE, MICHAEL ALLEN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:GOEDDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10243
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96721-5243
Mailing Address - Country:US
Mailing Address - Phone:808-437-8200
Mailing Address - Fax:808-201-9892
Practice Address - Street 1:120 KEAWE ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2874
Practice Address - Country:US
Practice Address - Phone:808-437-8200
Practice Address - Fax:808-201-9892
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI61-203992083A0300X
VT042-00127322084P0800X
HIMD-216382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine