Provider Demographics
NPI:1114452588
Name:JACK, GODLY OBOMATE (MD)
Entity Type:Individual
Prefix:
First Name:GODLY
Middle Name:OBOMATE
Last Name:JACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:150 GENTILLY BLVD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8522
Practice Address - Country:US
Practice Address - Phone:470-490-6670
Practice Address - Fax:770-382-5762
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA98756207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease