Provider Demographics
NPI:1689635732
Name:GODEK, ANDREW JOSEPH (ATC, PT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JOSEPH
Last Name:GODEK
Suffix:
Gender:M
Credentials:ATC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 S. 18TH STREET
Mailing Address - Street 2:BAPTIST REHAB
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034
Mailing Address - Country:US
Mailing Address - Phone:904-321-3850
Mailing Address - Fax:
Practice Address - Street 1:1348 SOUTH 18TH STREET
Practice Address - Street 2:BAPTIST REHAB
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034
Practice Address - Country:US
Practice Address - Phone:904-321-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL20802255A2300X
FLPT26195225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEP938ZMedicare PIN