Healthcare Provider Details

I. General information

NPI: 1912402009
Provider Name (Legal Business Name): JORDY BRADY GODINEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E SAMPLE RD
DEERFIELD BEACH FL
33064-3502
US

IV. Provider business mailing address

FLORIDA ATLANTIC UNIVERSITY MEDICINE AT BOCA RATON 670 GLADES ROAD, SUITE 400
BOCA RATON FL
33431
US

V. Phone/Fax

Practice location:
  • Phone: 954-941-8300
  • Fax:
Mailing address:
  • Phone: 561-955-2570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME147869
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: