Provider Demographics
NPI:1881654705
Name:GODOY, CARLOS A
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:GODOY
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 1:33651 OAK POINT CIR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2768
Mailing Address - Country:US
Mailing Address - Phone:248-553-0717
Mailing Address - Fax:
Practice Address - Street 1:4700 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3698
Practice Address - Country:US
Practice Address - Phone:313-581-2600
Practice Address - Fax:313-581-0228
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICG033015207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236661OtherMEDICARE PROVIDER NO
MI1358084Medicaid
MI4471546OtherAETNA
MI340H210660OtherBCBSM/BCN
MI50801OtherOMNI A COVENTRY HEALTH PL
MI001015OtherMIDWEST HEALTH PLAN
MI112307OtherGREAT LAKES HEALTH PLAN
MI340H210660OtherBCBSM/BCN
MI50801OtherOMNI A COVENTRY HEALTH PL