Provider Demographics
NPI:1407012834
Name:GODBOLD, HENRI (MD)
Entity Type:Individual
Prefix:
First Name:HENRI
Middle Name:
Last Name:GODBOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HENRI
Other - Middle Name:
Other - Last Name:GODBOLD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 721471
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0471
Mailing Address - Country:US
Mailing Address - Phone:313-300-2024
Mailing Address - Fax:888-350-8965
Practice Address - Street 1:3956 MOUNT ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1841
Practice Address - Country:US
Practice Address - Phone:313-925-4540
Practice Address - Fax:313-925-4606
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080800207R00000X, 208000000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics