Provider Demographics
NPI:1417914847
Name:GODINEZ, JUAN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:GODINEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:
Other - Last Name:GODINEZ-PUEBLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7415 LAS COLINAS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-7569
Mailing Address - Country:US
Mailing Address - Phone:214-379-2722
Mailing Address - Fax:972-869-3875
Practice Address - Street 1:2010 BEN MERRITT DR UNIT A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3853
Practice Address - Country:US
Practice Address - Phone:940-626-2300
Practice Address - Fax:940-626-2315
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME708452085R0001X
MA2208502085R0001X
COCDR.00017812085R0001X
TXN63142085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01875021OtherRAILROAD
TX364030201Medicaid
FL251521OtherAVMED
FL258329100Medicaid
FL44853OtherBCBSFL
FLP00862529OtherRR MEDICARE
FLE1126TMedicare PIN
FL44853OtherBCBSFL
FLE1126QMedicare PIN
FLE1126JMedicare PIN
FLE1126VMedicare PIN
FLP00862529OtherRR MEDICARE
FLE1126PMedicare PIN
FLE1126UMedicare PIN
FLE1126XMedicare PIN
TX345479YKYCMedicare PIN
FL251521OtherAVMED
TX364030201Medicaid
FLE1126OMedicare PIN