Basic Information
Provider Information | |||||||||
NPI: | 1316207202 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOEDE | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | JUSTIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6716 NW 11TH PL STE 200 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 326054201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523319729 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6716 NW 11TH PL STE 200 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 32605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523319729 | ||||||||
FaxNumber: | 3523310136 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2012 | ||||||||
LastUpdateDate: | 03/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | ME135579 | FL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
ID | Type | State | Issuer | Description | JK894 | 01 |   | MEDICARE | OTHER | NFZVZ | 01 | FL | BCBS | OTHER | 024778300 | 05 | FL |   | MEDICAID | JK893 | 01 |   | MEDICARE | OTHER |