Provider Demographics
NPI:1780609974
Name:MIX, GODFREY FREDERICK (DPM)
Entity type:Individual
Prefix:DR
First Name:GODFREY
Middle Name:FREDERICK
Last Name:MIX
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5025 J ST
Mailing Address - Street 2:SUITE 316
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3839
Mailing Address - Country:US
Mailing Address - Phone:916-732-2277
Mailing Address - Fax:916-732-2280
Practice Address - Street 1:5025 J ST
Practice Address - Street 2:SUITE 316
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3839
Practice Address - Country:US
Practice Address - Phone:916-732-2277
Practice Address - Fax:916-732-2280
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1227213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10840Medicare UPIN
CA000E12270Medicare PIN