Healthcare Provider Details

I. General information

NPI: 1467422584
Provider Name (Legal Business Name): MELISSA A GOULART D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S GRAND AVE
SAINT MARYS KS
66536-1637
US

IV. Provider business mailing address

805 CEDAR TREE LN
ST MARYS KS
66536-1873
US

V. Phone/Fax

Practice location:
  • Phone: 785-437-3734
  • Fax: 785-437-6186
Mailing address:
  • Phone: 785-437-2542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0530124
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: