Basic Information
| Provider Information | |||||||||
| NPI: | 1649474719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODFREY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1151 HOSPITAL WAY | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326616 | ||||||||
| FaxNumber: | 2082326618 | ||||||||
| Practice Location | |||||||||
| Address1: | 1151 HOSPITAL WAY | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326616 | ||||||||
| FaxNumber: | 2082326618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
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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 | 207RG0100X | M-11289 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0100X | 2010012205 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.