Healthcare Provider Details

I. General information

NPI: 1679652689
Provider Name (Legal Business Name): ERIC J GOTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W HART RD
BELOIT WI
53511
US

IV. Provider business mailing address

340 MIDLAND RD STE 120
JANESVILLE WI
53546-2339
US

V. Phone/Fax

Practice location:
  • Phone: 608-362-7888
  • Fax: 608-362-8470
Mailing address:
  • Phone: 608-743-9313
  • Fax: 608-743-9318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-129967
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number51248-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: