Provider Demographics
NPI:1467405845
Name:GODENICK, MARK TODD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TODD
Last Name:GODENICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:853 N CHURCH ST
Practice Address - Street 2:SUITE 510
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3098
Practice Address - Country:US
Practice Address - Phone:864-560-6193
Practice Address - Fax:864-560-1510
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14616207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA96196067OtherMEDICARE PIN
SCA723895019OtherMEDICARE PIN
SC4455408OtherAETNA
SCA723893365OtherMEDICARE PIN
SCD6334OtherMEDCOST
SCTL3829Medicaid
SCA723895019Medicare PIN
SCA72389Medicare UPIN
SCA72389Medicare PIN
SCA723893365Medicare PIN