Provider Demographics
NPI:1831175371
Name:GODICH, PAUL MARTIN
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MARTIN
Last Name:GODICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 S 108TH ST
Mailing Address - Street 2:STE 204
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-1237
Mailing Address - Country:US
Mailing Address - Phone:414-453-1010
Mailing Address - Fax:414-425-4230
Practice Address - Street 1:3670 S 108TH ST
Practice Address - Street 2:STE 204
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-1237
Practice Address - Country:US
Practice Address - Phone:414-453-1010
Practice Address - Fax:414-425-4230
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1297152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38501000Medicaid
WIT62017Medicare UPIN
WI38501000Medicaid
WI1148050001Medicare NSC