MEDICARE: BETH A GOETZ CPT

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	174H00000X	Health Educator

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	647679	OTHER	OK	MEDICARE DIABETIC PREVENTION PROGRAM

General Provider Information

NPI Number	:	1659879856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH A GOETZ CPT

Provider Business Mailing Address
First Line	:	1000 N LINCOLN BLVD STE 1308
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-3252
Country	:	US
Telephone Number	:	405-421-2959
Fax Number	:	405-271-2836

Provider Business Practice Location Address
First Line	:	1000 N LINCOLN BLVD STE 1308
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-3252
Country	:	US
Telephone Number	:	405-421-2959
Fax Number	:	405-271-2836

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

Provider Enumeration Date	:	01/23/2018
Last Update Date	:	09/21/2018

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