Basic Information
| Provider Information | |||||||||
| NPI: | 1093917221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODDARD | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178516110 | ||||||||
| FaxNumber: | 7178482074 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PINE GROVE CMNS | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178516110 | ||||||||
| FaxNumber: | 7177411076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD459118 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | 46080 | KY | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0102X | MD459118 | PA | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 103179835 | 05 | PA | MEDICAID | PO1804579 | 01 | PA | RAILROAD MEDICARE | OTHER |