Healthcare Provider Details

I. General information

NPI: 1720806482
Provider Name (Legal Business Name): GERARDO ANGEL GODINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 EUCLID AVE STE 207
SAN DIEGO CA
92114-3612
US

IV. Provider business mailing address

286 EUCLID AVE STE 207
SAN DIEGO CA
92114-3612
US

V. Phone/Fax

Practice location:
  • Phone: 619-859-6270
  • Fax:
Mailing address:
  • Phone: 619-859-6270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-NYPLJW
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: