Healthcare Provider Details

I. General information

NPI: 1154483089
Provider Name (Legal Business Name): CHARLES MICHAEL GODDARD II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7275 SAWMILL ROAD NORTHWEST PEDIATRICS, INC.
DUBLIN OH
43016
US

IV. Provider business mailing address

7275 SAWMILL ROAD NORTHWEST PEDIATRICS, INC.
DUBLIN OH
43016
US

V. Phone/Fax

Practice location:
  • Phone: 614-766-6321
  • Fax: 614-766-0193
Mailing address:
  • Phone: 614-766-6321
  • Fax: 614-766-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number059637
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number069707
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: