Basic Information
| Provider Information | |||||||||
| NPI: | 1467413765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODINEZ | ||||||||
| FirstName: | ANISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 678342 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752678342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122444400 | ||||||||
| FaxNumber: | 5122444752 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 HESTERS CROSSING RD | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786818025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122444400 | ||||||||
| FaxNumber: | 5122444752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 11/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | J4821 | TX | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 089777902 | 05 | TX | MEDICAID |