Provider Demographics
NPI:1770704850
Name:GODFREY, JOHN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GODFREY
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N BROAD ST
Mailing Address - Street 2:FL 3
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:610-876-2400
Mailing Address - Fax:215-463-3820
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:BLDG 1 SUITE 400
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:610-876-2400
Practice Address - Fax:610-876-4308
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07805800174400000X
PAOS012390207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102104615 0002Medicaid
PA119232GT6Medicare PIN