Healthcare Provider Details

I. General information

NPI: 1073517983
Provider Name (Legal Business Name): DAVID WILLIAM GOETZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1063 MAPLE DR SUITE 1A
MORGANTOWN WV
26505-2848
US

IV. Provider business mailing address

100 AVERY OLIVIA WAY SUITE C
FAIRMONT WV
26554-9375
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-2992
  • Fax: 304-598-5901
Mailing address:
  • Phone: 304-363-7000
  • Fax: 304-366-7413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberNA
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: