1003004706 NPI number — HENRY G. GODFREY, M.D., P.C.

Table of content: JEFFREY DARREL HANZON D.M.D. (NPI 1275629115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003004706 NPI number — HENRY G. GODFREY, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HENRY G. GODFREY, M.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003004706
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20-01 MAPLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIR LAWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07410-1523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-791-8088
Provider Business Mailing Address Fax Number:
201-791-2202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10035-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-987-1777
Provider Business Practice Location Address Fax Number:
212-987-1776
Provider Enumeration Date:
10/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GODFREY
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
212-987-1777

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  130605 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0833H . This is a "EMPIRE BLUE CROSS BLUE SH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00622904 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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