Provider Demographics
NPI:1407835572
Name:GODDARD, DWIGHT JUSTIN (MD)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:JUSTIN
Last Name:GODDARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:270 GOOSEPOND RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3104
Mailing Address - Country:US
Mailing Address - Phone:220-564-7960
Mailing Address - Fax:220-564-7961
Practice Address - Street 1:270 GOOSEPOND RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3104
Practice Address - Country:US
Practice Address - Phone:220-564-7960
Practice Address - Fax:220-564-7961
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63539207Q00000X
OH35.137356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG63539OtherSTATE LICENSE
CAG63539OtherSTATE LICENSE
E93672Medicare UPIN