Provider Demographics
NPI:1659329241
Name:GODFREY, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:GODFREY
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 1:833 TOWNE CT
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1280
Mailing Address - Country:US
Mailing Address - Phone:817-306-5630
Mailing Address - Fax:817-306-5631
Practice Address - Street 1:833 TOWNE CT
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76179-1280
Practice Address - Country:US
Practice Address - Phone:817-306-5630
Practice Address - Fax:817-306-5631
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138088315Medicaid
TX138088314Medicaid
TXP00441682OtherRAILROAD MEDICARE
TXD87440Medicare UPIN
TX138088314Medicaid