=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912298902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARLOS A GODOY M D P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2011
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17920 FARMINGTON RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-909-1334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17920 FARMINGTON RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | KELLY OWENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-459-7444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | CG033015
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------