Provider Demographics
NPI:1366502692
Name:GODDARD, MARK ERIC (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ERIC
Last Name:GODDARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:102 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-4115
Mailing Address - Country:US
Mailing Address - Phone:610-363-1871
Mailing Address - Fax:610-363-0280
Practice Address - Street 1:80 W WELSH POOL RD
Practice Address - Street 2:SUITE 106
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1233
Practice Address - Country:US
Practice Address - Phone:610-363-1871
Practice Address - Fax:610-363-0280
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE006360T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA038997Medicare ID - Type Unspecified