Provider Demographics
NPI:1023009362
Name:GODFREY, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:GODFREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 N DIXIE AVE
Mailing Address - Street 2:STE 304
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2520
Mailing Address - Country:US
Mailing Address - Phone:270-769-1049
Mailing Address - Fax:270-735-1978
Practice Address - Street 1:914 N DIXIE AVE
Practice Address - Street 2:STE 304
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2520
Practice Address - Country:US
Practice Address - Phone:270-769-1049
Practice Address - Fax:270-735-1978
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36738207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64033905Medicaid
G97229Medicare UPIN
KY64033905Medicaid