Provider Demographics
NPI:1295711240
Name:GODDARD, JERRY L (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:L
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 1:305 W JACKSON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1474
Mailing Address - Country:US
Mailing Address - Phone:618-536-6621
Mailing Address - Fax:618-453-1102
Practice Address - Street 1:305 W JACKSON ST
Practice Address - Street 2:STE 200
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-536-6621
Practice Address - Fax:618-453-1102
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054846207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054846Medicaid
IL036054846Medicaid
ILL60277Medicare ID - Type Unspecified