Provider Demographics
NPI:1417002841
Name:GODFREY, STEPHEN COURTNEY (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:COURTNEY
Last Name:GODFREY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3107
Mailing Address - Country:US
Mailing Address - Phone:415-482-6707
Mailing Address - Fax:
Practice Address - Street 1:1033 3RD ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3107
Practice Address - Country:US
Practice Address - Phone:415-482-6707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8476T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist