Provider Demographics
NPI:1164439261
Name:GODNER, MARVIN JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:JORDAN
Last Name:GODNER
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 1:2313 CALLE COLIBRI
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6301
Mailing Address - Country:US
Mailing Address - Phone:505-983-0507
Mailing Address - Fax:
Practice Address - Street 1:711 PUEBLO MAIN STREET
Practice Address - Street 2:
Practice Address - City:SAN FELIPE PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87001
Practice Address - Country:US
Practice Address - Phone:505-867-3365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM75-38208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics