MEDICARE: DR. JAMES L GODARD DO

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	R7G85	MO

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	110031981	OTHER		RR MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1558366724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES L GODARD DO

Provider Business Mailing Address
First Line	:	1540 E EVERGREEN ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-4300
Country	:	US
Telephone Number	:	417-823-2900
Fax Number	:	417-886-2774

Provider Business Practice Location Address
First Line	:	1540 E EVERGREEN ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-4300
Country	:	US
Telephone Number	:	417-823-2900
Fax Number	:	417-886-2774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	01/15/2019

2101 E JEFFERSON ST , KAISER PERMANENTE SPRINGFIELD MEDICARE ENROLLMENT
ROCKVILLE, MD
20852-4908

Practice Phone: 701-922-1000
Practice Fax: 703-922-1039