Provider Demographics
NPI:1053651596
Name:GODICK, SIMEON DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SIMEON
Middle Name:DAVID
Last Name:GODICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8430 122ND ST
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3234
Mailing Address - Country:US
Mailing Address - Phone:917-328-0975
Mailing Address - Fax:
Practice Address - Street 1:5715 16TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1811
Practice Address - Country:US
Practice Address - Phone:718-972-7432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant