Healthcare Provider Details

I. General information

NPI: 1912298902
Provider Name (Legal Business Name): CARLOS A GODOY M D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17920 FARMINGTON RD
LIVONIA MI
48152-3104
US

IV. Provider business mailing address

17920 FARMINGTON RD
LIVONIA MI
48152-3104
US

V. Phone/Fax

Practice location:
  • Phone: 313-909-1334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberCG033015
License Number StateMI

VIII. Authorized Official

Name: KELLY OWENS
Title or Position: CREDENTIALING
Credential:
Phone: 734-459-7444