MEDICARE: DR. EMILY REITER GODDARD MD

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	2084F0202X	Forensic Psychiatry Physician	ME 109494	FL
2	2084P0804X	Child & Adolescent Psychiatry Physician	ME 109494	FL
3	2084P0800X	Psychiatry Physician	ME 109494	FL
4	2084P0804X	Child & Adolescent Psychiatry Physician	A108455	CA
5	2084P0800X	Psychiatry Physician	A108455	CA

General Provider Information

NPI Number	:	1922195981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EMILY REITER GODDARD MD

Provider Business Mailing Address
First Line	:	8491 NW 39TH AVE
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32606-5635
Country	:	US
Telephone Number	:	352-265-3284
Fax Number	:	352-265-3285

Provider Business Practice Location Address
First Line	:	8491 NW 39TH AVE
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32606-5635
Country	:	US
Telephone Number	:	352-265-3284
Fax Number	:	352-265-3285

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

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	07/06/2011

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