Provider Demographics
NPI:1376575738
Name:GODFREY, CRAIG R (DO)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:R
Last Name:GODFREY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 LIBERTY ST
Mailing Address - Street 2:SUITE # 301
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2566
Mailing Address - Country:US
Mailing Address - Phone:814-724-8363
Mailing Address - Fax:814-724-8343
Practice Address - Street 1:765 LIBERTY ST
Practice Address - Street 2:SUITE # 301
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2566
Practice Address - Country:US
Practice Address - Phone:814-724-8363
Practice Address - Fax:814-724-8343
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004699L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA127917OtherBLUE CROSS / SHIELD
PAB37474Medicare UPIN
PA116537Medicare PIN