Provider Demographics
NPI:1174563332
Name:GODDARD, RICHARD MARK (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARK
Last Name:GODDARD
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 1:5409 AVENUE 0
Mailing Address - Street 2:SUITE 122
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627
Mailing Address - Country:US
Mailing Address - Phone:319-376-2400
Mailing Address - Fax:319-376-2422
Practice Address - Street 1:5445 AVENUE O
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9611
Practice Address - Country:US
Practice Address - Phone:319-768-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT116496935-1205207V00000X
IAMD-31157207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G676600Medicaid
CAG90747Medicare UPIN
CA00G676600Medicaid