MEDICARE: JOHN W GOULART DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	4191	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00155199	OTHER	OK	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417957085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN W GOULART DO

Provider Business Mailing Address
First Line	:	5300 N INDEPENDENCE AVE
Second Line	:	280
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-5556
Country	:	US
Telephone Number	:	580-234-2289
Fax Number	:	580-249-4350

Provider Business Practice Location Address
First Line	:	620 S MADISON ST
Second Line	:	SUITE 108
City	:	ENID
State	:	OK
Zip	:	73701-7270
Country	:	US
Telephone Number	:	580-234-2289
Fax Number	:	580-249-4350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	02/09/2018

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Directions to “ JOHN W GOULART DO” Practice Location

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