Healthcare Provider Details

I. General information

NPI: 1588958227
Provider Name (Legal Business Name): CASEY ELISABETH GODSHALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2011
Last Update Date: 09/28/2022
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-8022
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8022
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4225
  • Fax: 860-679-1217
Mailing address:
  • Phone: 860-679-4225
  • Fax: 860-679-1217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT199729
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number056858
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: