Provider Demographics
NPI:1942534334
Name:GOFORTH, DOUGLAS (DPM)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:DPM
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 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-2186
Mailing Address - Fax:970-858-2208
Practice Address - Street 1:401 KOKOPELLI BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-3308
Practice Address - Country:US
Practice Address - Phone:970-858-2530
Practice Address - Fax:970-858-1196
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000712213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCA2213OtherMEDICARE GROUP
CO04674731Medicaid
CO1720207863OtherNPI GROUP
CO1152560002Medicare NSC
COA108902Medicare UPIN