Basic Information
| Provider Information | |||||||||
| NPI: | 1114410529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOETTEL | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 621 S ILLINOIS AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504015489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414283041 | ||||||||
| FaxNumber: | 6414283059 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 4TH ST SW STE 340 | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504012856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414287766 | ||||||||
| FaxNumber: | 6414287788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2018 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R-11217 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD-48013 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.