Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 5851 | AZ |
NPI | 1194727396 |
---|---|
Provider Name | Dr. Gerald Craig Godard |
First Address | Mesa, AZ 85215-1148 |
Second Address | Mesa, AZ 85215-1148 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2005 |
Last Update Date | 30/03/2012 |