Healthcare Provider Details

I. General information

NPI: 1407012834
Provider Name (Legal Business Name): HENRI GODBOLD M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: HENRI GODBOLD M.D.

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20901 W 7 MILE RD
DETROIT MI
48219-1904
US

IV. Provider business mailing address

18000 W 9 MILE RD STE 200
SOUTHFIELD MI
48075-4020
US

V. Phone/Fax

Practice location:
  • Phone: 313-564-5510
  • Fax: 248-581-8839
Mailing address:
  • Phone: 248-336-4000
  • Fax: 248-336-9137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301080800
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301080800
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301080800
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: