Provider Demographics
NPI:1649474719
Name:GODFREY, JONATHAN D (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:D
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 1:1151 HOSPITAL WAY
Mailing Address - Street 2:BUILDING A
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5091
Mailing Address - Country:US
Mailing Address - Phone:208-232-6616
Mailing Address - Fax:208-232-6618
Practice Address - Street 1:1151 HOSPITAL WAY
Practice Address - Street 2:BUILDING A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5091
Practice Address - Country:US
Practice Address - Phone:208-232-6616
Practice Address - Fax:208-232-6618
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11289207RG0100X
390200000X
MO2010012205207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110012024Medicare PIN