Healthcare Provider Details

I. General information

NPI: 1437155710
Provider Name (Legal Business Name): ROY GODDARD JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E PECAN ST
ALTUS OK
73521-6141
US

IV. Provider business mailing address

PO BOX 8190
ALTUS OK
73522-8190
US

V. Phone/Fax

Practice location:
  • Phone: 580-482-4781
  • Fax: 580-481-2345
Mailing address:
  • Phone: 580-482-4781
  • Fax: 580-481-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2523
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: