Provider Demographics
NPI:1821181322
Name:GODFREY, GREGG MARK (DC)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:MARK
Last Name:GODFREY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 S COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:ARANSAS PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78336
Mailing Address - Country:US
Mailing Address - Phone:361-758-6224
Mailing Address - Fax:361-758-7749
Practice Address - Street 1:246 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ARANSAS PASS
Practice Address - State:TX
Practice Address - Zip Code:78336
Practice Address - Country:US
Practice Address - Phone:361-758-6224
Practice Address - Fax:361-758-7749
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7289111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001998601Medicaid
TX0004HQOtherBCBS
TX001998601Medicaid
TXU66702Medicare UPIN