Individual
BRYAN L GODDARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2524 ROUTE 9W, RAVENA, NY 12143-2804
(518) 756-7390
(518) 756-8030
Mailing address
711 TROY SCHENECTADY RD STE 203, LATHAM, NY 12110-2461
(518) 782-3700
(518) 782-3799
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
150318
NY
207Q00000X
Family Medicine Physician
2008004918
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00751111
—
NY
01
—
101115000088
FIDELIS
NY
01
—
305800
SENIOR WHOLE HEALTH
NY
01
—
4228179
AETNA
NY
01
—
642981
GHI/HMO
NY
01
—
6754C1
EMPIRE BC
NY
01
—
PRC110032213
CDPHP
NY
Enumeration date
08/31/2005
Last updated
01/18/2018
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