Healthcare Provider Details

I. General information

NPI: 1073876504
Provider Name (Legal Business Name): DR. JEFFERY ALLEN GOAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N GLASSELL ST
ORANGE CA
92866-1034
US

IV. Provider business mailing address

9401 JERONIMO RD
IRVINE CA
92618-1908
US

V. Phone/Fax

Practice location:
  • Phone: 714-744-7077
  • Fax:
Mailing address:
  • Phone: 714-516-5491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number47375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: