Healthcare Provider Details

I. General information

NPI: 1053824763
Provider Name (Legal Business Name): ERIC M. GODDARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7916 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-434-6322
  • Fax: 260-434-6481
Mailing address:
  • Phone: 260-479-3514
  • Fax: 260-479-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002367A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: