Provider Demographics
NPI:1710531942
Name:GODDRIDGE, GEORGE EMIL
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:EMIL
Last Name:GODDRIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6313
Mailing Address - Country:US
Mailing Address - Phone:954-547-2675
Mailing Address - Fax:
Practice Address - Street 1:7777 GRANDE ST
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6313
Practice Address - Country:US
Practice Address - Phone:954-547-2675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJF130454171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty