Healthcare Provider Details

I. General information

NPI: 1407318363
Provider Name (Legal Business Name): TRAVIS GOETTEMOELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 S NEIL ST
CHAMPAIGN IL
61820-7215
US

IV. Provider business mailing address

1807 S NEIL ST
CHAMPAIGN IL
61820-7215
US

V. Phone/Fax

Practice location:
  • Phone: 217-359-4745
  • Fax:
Mailing address:
  • Phone: 217-359-4745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number180381
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: