Healthcare Provider Details

I. General information

NPI: 1730278375
Provider Name (Legal Business Name): JOHN CHRISTOPHER GODDARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD SUNNYBROOK MEDICAL BUILDING, DEPT OF OTOLARYNGOLOGY
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

10180 SE SUNNYSIDE RD SUNNYBROOK MEDICAL BUILDING, DEPT OF OTOLARYNGOLOGY
CLACKAMAS OR
97015-8970
US

V. Phone/Fax

Practice location:
  • Phone: 503-571-3495
  • Fax: 503-571-9004
Mailing address:
  • Phone: 503-571-3495
  • Fax: 503-571-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD166617
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberME 109697
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberA107625
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberMD166617
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberMD 60454681
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: