MEDICARE: DR. JOHN BRADLEY GOFORTH D.O.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	O-1517	ID

General Provider Information

NPI Number	:	1912432550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN BRADLEY GOFORTH D.O.

Provider Business Mailing Address
First Line	:	1072 N LIBERTY ST STE 100
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8708
Country	:	US
Telephone Number	:	208-302-1200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1072 N LIBERTY STREET
Second Line	:	STE 100
City	:	BOISE
State	:	ID
Zip	:	83704-8706
Country	:	US
Telephone Number	:	208-302-1200
Fax Number	:

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

Provider Enumeration Date	:	04/20/2017
Last Update Date	:	06/16/2021

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