Provider Demographics
NPI:1629495833
Name:GODFREY, BRANDON WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:WALLACE
Last Name:GODFREY
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 1:111 S 11TH AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3273
Mailing Address - Country:US
Mailing Address - Phone:509-454-8888
Mailing Address - Fax:
Practice Address - Street 1:2811 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3761
Practice Address - Country:US
Practice Address - Phone:509-575-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ51008207P00000X
NV23560207P00000X
WA61518892207PS0010X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine