Healthcare Provider Details

I. General information

NPI: 1508841974
Provider Name (Legal Business Name): BRENT W GODEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 GEARY ST SE
ALBANY OR
97322-6842
US

IV. Provider business mailing address

PO BOX 1188
CORVALLIS OR
97339-1188
US

V. Phone/Fax

Practice location:
  • Phone: 541-812-5570
  • Fax: 541-812-5699
Mailing address:
  • Phone: 541-812-5570
  • Fax: 541-812-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD151050
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: