Provider Demographics
NPI:1659358018
Name:GODFREY, HENRY G (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:G
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 1:20-01 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1523
Mailing Address - Country:US
Mailing Address - Phone:201-791-8088
Mailing Address - Fax:201-791-2202
Practice Address - Street 1:1919 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2745
Practice Address - Country:US
Practice Address - Phone:212-987-1777
Practice Address - Fax:212-987-1776
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1306052086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00622904Medicaid
NY51A111OtherEMPIRE BLUE CROSS BLUE SH
NY00622904Medicaid
NYB15707Medicare UPIN