Healthcare Provider Details

I. General information

NPI: 1790952604
Provider Name (Legal Business Name): DAVID MICHAEL GODFREY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2212 MIFFLIN AVE SUITE 220
ASHLAND OH
44805-8848
US

IV. Provider business mailing address

2212 MIFFLIN AVE SUITE 220
ASHLAND OH
44805-8848
US

V. Phone/Fax

Practice location:
  • Phone: 419-207-2663
  • Fax: 419-289-4631
Mailing address:
  • Phone: 419-207-2663
  • Fax: 419-289-4631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number35.095862
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: