Provider Demographics
NPI:1265471411
Name:GODFREY, PHILIP MAITLAND (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:MAITLAND
Last Name:GODFREY
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CAFFREY AVE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-1433
Mailing Address - Country:US
Mailing Address - Phone:917-435-6225
Mailing Address - Fax:718-939-6235
Practice Address - Street 1:62 CAFFREY AVE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-1433
Practice Address - Country:US
Practice Address - Phone:917-435-6225
Practice Address - Fax:718-939-6235
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158384174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA64035Medicare UPIN
NY69433BMedicare PIN