Healthcare Provider Details

I. General information

NPI: 1245200906
Provider Name (Legal Business Name): GODSON IFEANYI OGUCHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 TOWN CENTER DR SUITE 100
ORANGE CITY FL
32763-8255
US

IV. Provider business mailing address

PO BOX 471027
LAKE MONROE FL
32747-1027
US

V. Phone/Fax

Practice location:
  • Phone: 386-228-0661
  • Fax: 386-228-0662
Mailing address:
  • Phone: 386-228-0661
  • Fax: 386-228-0662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME89341
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME89341
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: