Basic Information
| Provider Information | |||||||||
| NPI: | 1780678169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODDARD | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 2524 ROUTE 9W | ||||||||
| Address2: | |||||||||
| City: | RAVENA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121432804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187567390 | ||||||||
| FaxNumber: | 5187568030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2008004918 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 150318 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6754C1 | 01 | NY | EMPIRE BC | OTHER | 4228179 | 01 | NY | AETNA | OTHER | 101115000088 | 01 | NY | FIDELIS | OTHER | PRC110032213 | 01 | NY | CDPHP | OTHER | 00751111 | 05 | NY | MEDICAID | 305800 | 01 | NY | SENIOR WHOLE HEALTH | OTHER | 642981 | 01 | NY | GHI/HMO | OTHER |