MEDICARE: PAUL MARTIN GODICH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1297	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831175371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL MARTIN GODICH

Provider Business Mailing Address
First Line	:	3670 S 108TH ST
Second Line	:	STE 204
City	:	GREENFIELD
State	:	WI
Zip	:	53228-1237
Country	:	US
Telephone Number	:	414-453-1010
Fax Number	:	414-425-4230

Provider Business Practice Location Address
First Line	:	3670 S 108TH ST
Second Line	:	STE 204
City	:	GREENFIELD
State	:	WI
Zip	:	53228-1237
Country	:	US
Telephone Number	:	414-453-1010
Fax Number	:	414-425-4230

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	01/25/2017

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Directions to “ PAUL MARTIN GODICH ” Practice Location

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