Provider Demographics
NPI:1487606323
Name:GODDARD, MARK ADAM (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ADAM
Last Name:GODDARD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2050 OAK MOUNTAIN DR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-1368
Mailing Address - Country:US
Mailing Address - Phone:205-621-5780
Mailing Address - Fax:205-621-9780
Practice Address - Street 1:2050 OAK MOUNTAIN DR
Practice Address - Street 2:SUITE 7
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-1368
Practice Address - Country:US
Practice Address - Phone:205-621-5780
Practice Address - Fax:205-621-9780
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-02-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AL000200132085R0202X
FLME817002085R0202X
GA0495372085R0202X
MI43010584072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051533737OtherBLUE CROSS
ALG08585Medicare UPIN