Provider Demographics
NPI:1861003220
Name:GODINEZ, SERGIO VINCENTE JR
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:VINCENTE
Last Name:GODINEZ
Suffix:JR
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 1:1695 N SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-3701
Mailing Address - Country:US
Mailing Address - Phone:760-323-2111
Mailing Address - Fax:
Practice Address - Street 1:1695 N SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-3701
Practice Address - Country:US
Practice Address - Phone:760-323-2118
Practice Address - Fax:760-416-1651
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty