Healthcare Provider Details

I. General information

NPI: 1669805594
Provider Name (Legal Business Name): HEIDI MAY GODDARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SOQUEL DR
SANTA CRUZ CA
95065
US

IV. Provider business mailing address

415 14TH AVE
SANTA CRUZ CA
95062-4821
US

V. Phone/Fax

Practice location:
  • Phone: 831-462-7700
  • Fax:
Mailing address:
  • Phone: 503-312-0589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberAM1090896-08
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA159958
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: