Provider Demographics
NPI:1760518245
Name:GODIKSEN, MARK V (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:V
Last Name:GODIKSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:688 MEDICAL CENTER DR E
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6807
Mailing Address - Country:US
Mailing Address - Phone:559-297-8604
Mailing Address - Fax:559-297-0625
Practice Address - Street 1:688 MEDICAL CENTER DR E
Practice Address - Street 2:SUITE 106
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6807
Practice Address - Country:US
Practice Address - Phone:559-297-8604
Practice Address - Fax:559-297-0625
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA43850207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A438500Medicaid
CAE27918Medicare UPIN
CA00A438500Medicaid