Basic Information
| Provider Information | |||||||||
| NPI: | 1467408773 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODFREY | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 159 | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167010159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143683123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 51 BOYLSTON ST | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167012009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143683123 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 02/05/2010 | ||||||||
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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 | 208800000X | MD045174E | PA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0010900580002 | 05 | PA | MEDICAID |