Healthcare Provider Details

I. General information

NPI: 1124334792
Provider Name (Legal Business Name): WAYNE RUSSELL GODFREY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 04/07/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4927 NE TOLO RD
BAINBRIDGE ISLAND WA
98110-3467
US

IV. Provider business mailing address

4927 NE TOLO RD
BAINBRIDGE ISLAND WA
98110-3467
US

V. Phone/Fax

Practice location:
  • Phone: 650-521-2770
  • Fax:
Mailing address:
  • Phone: 650-521-2770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberG68658
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number00044509
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: