Healthcare Provider Details

I. General information

NPI: 1093917221
Provider Name (Legal Business Name): JESSE GODDARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PINE GROVE CMNS
YORK PA
17403-5176
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 717-851-6110
  • Fax: 717-741-1076
Mailing address:
  • Phone: 717-851-6110
  • Fax: 717-848-2074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD459118
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number46080
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD459118
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: