Provider Demographics
NPI:1124381751
Name:GODLEY, ROBERT W II (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:GODLEY
Suffix:II
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 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7588
Mailing Address - Fax:
Practice Address - Street 1:COMMUNITY PHYSICIANS OF INDIANA, INC.
Practice Address - Street 2:1402 E. COUNTY LINE RAD
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0963
Practice Address - Country:US
Practice Address - Phone:317-887-7880
Practice Address - Fax:317-887-7886
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100740390200000X
TXBP10052864390200000X
IN01081921A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP02559041OtherRR MEDICARE
IN300026003Medicaid