Provider Demographics
NPI:1699959163
Name:GODDARD, AMANDA (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 NUTTER WAY
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8715
Mailing Address - Country:US
Mailing Address - Phone:781-608-3339
Mailing Address - Fax:
Practice Address - Street 1:887 CONGRESS ST STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-662-5522
Practice Address - Fax:207-662-5524
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60019802208000000X
390200000X
MA247365208000000X
MEMD226322080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program