Provider Demographics
NPI:1992719876
Name:GODAR, STEPHEN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:EDWARD
Last Name:GODAR
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 905
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701
Mailing Address - Country:US
Mailing Address - Phone:970-867-4911
Mailing Address - Fax:
Practice Address - Street 1:231 PROSPECT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701
Practice Address - Country:US
Practice Address - Phone:970-867-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34790207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21227039Medicaid
COC807398Medicare PIN
CO21227039Medicaid