Provider Demographics
NPI:1982627196
Name:GOFFAS, GEORGE THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:THOMAS
Last Name:GOFFAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22631 GREATER MACK AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2055
Mailing Address - Country:US
Mailing Address - Phone:586-773-6900
Mailing Address - Fax:586-773-5851
Practice Address - Street 1:22631 GREATER MACK AVE
Practice Address - Street 2:STE 200
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2055
Practice Address - Country:US
Practice Address - Phone:586-773-6900
Practice Address - Fax:586-773-5851
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901014708204E00000X
MI4301064416208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OM20380Medicare ID - Type Unspecified
F72991Medicare UPIN