Provider Demographics
NPI:1306981345
Name:GODDARD, MATTHEW ALAN
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALAN
Last Name:GODDARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 N PINE GROVE AVE APT 13C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6103
Mailing Address - Country:US
Mailing Address - Phone:773-327-3228
Mailing Address - Fax:773-327-1054
Practice Address - Street 1:2515 N CLARK ST STE 802
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2730
Practice Address - Country:US
Practice Address - Phone:773-327-3228
Practice Address - Fax:773-327-1054
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist