Provider Demographics
NPI:1245200906
Name:OGUCHI, GODSON IFEANYI (MD)
Entity Type:Individual
Prefix:MR
First Name:GODSON
Middle Name:IFEANYI
Last Name:OGUCHI
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:PO BOX 471027
Mailing Address - Street 2:
Mailing Address - City:LAKE MONROE
Mailing Address - State:FL
Mailing Address - Zip Code:32747-1027
Mailing Address - Country:US
Mailing Address - Phone:386-228-0661
Mailing Address - Fax:386-228-0662
Practice Address - Street 1:955 TOWN CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8255
Practice Address - Country:US
Practice Address - Phone:386-228-0661
Practice Address - Fax:386-228-0662
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89341207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17918OtherFL MEMORIAL HEALTH NETWOR
FL269494800Medicaid
FL264127OtherHEALTHEASE
FL46111OtherBC/BS
FLP00145723OtherRR MEDICARE
FL46111OtherBC/BS
FL264127OtherHEALTHEASE