Healthcare Provider Details

I. General information

NPI: 1760439095
Provider Name (Legal Business Name): DOUGLAS GODERWIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 TURFWAY RD
FLORENCE KY
41042-1375
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-212-4700
  • Fax: 859-212-4761
Mailing address:
  • Phone: 859-212-4700
  • Fax: 859-212-4761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27947
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27947
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: