Healthcare Provider Details

I. General information

NPI: 1043356892
Provider Name (Legal Business Name): STEPHEN E GODAR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 PROSPECT ST SUITE A
FORT MORGAN CO
80701-3161
US

IV. Provider business mailing address

PO BOX 905
FORT MORGAN CO
80701-0905
US

V. Phone/Fax

Practice location:
  • Phone: 970-867-4911
  • Fax:
Mailing address:
  • Phone: 970-867-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34790
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34790
License Number StateCO

VIII. Authorized Official

Name: MRS. SHELLEY HARPER
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 970-867-4911