Basic Information
Provider Information | |||||||||
NPI: | 1770701104 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILLIAM D. GOUDY D.O., PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1306 E 7TH ST | ||||||||
Address2: | SUITE B | ||||||||
City: | AUBURN | ||||||||
State: | IN | ||||||||
PostalCode: | 467062537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2609271982 | ||||||||
FaxNumber: | 2609278380 | ||||||||
Practice Location | |||||||||
Address1: | 1306 E 7TH ST | ||||||||
Address2: | SUITE B | ||||||||
City: | AUBURN | ||||||||
State: | IN | ||||||||
PostalCode: | 467062537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2609271982 | ||||||||
FaxNumber: | 2609278380 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2007 | ||||||||
LastUpdateDate: | 12/28/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOUDY | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2609271982 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 000000335961 | 01 | IN | ANTHEM | OTHER | DC0427 | 01 | IN | MEDICARE RAILROAD | OTHER | 100103820A | 05 | IN |   | MEDICAID |