Individual
JERRY L GODDARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
305 W JACKSON ST, STE 200, CARBONDALE, IL 62901-1474
(618) 536-6621
(618) 453-1102
Mailing address
305 W JACKSON ST, STE 200, CARBONDALE, IL 62901-1474
(618) 536-6621
(618) 453-1102
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036-054846
IL
207QS0010X
Sports Medicine (Family Medicine) Physician
036-054846
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036054846
—
IL
Enumeration date
12/21/2005
Last updated
12/28/2020
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