Provider Demographics
NPI:1871556746
Name:GODBOLD, DONALD TERRENCE (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:TERRENCE
Last Name:GODBOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1883 GIBBS AVE
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-8469
Mailing Address - Country:US
Mailing Address - Phone:209-358-3701
Mailing Address - Fax:
Practice Address - Street 1:3916 STATE ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-5602
Practice Address - Country:US
Practice Address - Phone:800-563-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51364207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A513640Medicaid
CA00A513641Medicare ID - Type Unspecified
CABN888ZMedicare PIN
CA00A513640Medicaid
CAE69670Medicare UPIN
CAAR918ZMedicare PIN