Provider Demographics
NPI:1588292049
Name:GODINICH, VINCENT CODY (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:CODY
Last Name:GODINICH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:HARLETON
Mailing Address - State:TX
Mailing Address - Zip Code:75651-4126
Mailing Address - Country:US
Mailing Address - Phone:903-407-2605
Mailing Address - Fax:
Practice Address - Street 1:7551 YOUREE DR STE 11
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5533
Practice Address - Country:US
Practice Address - Phone:318-642-9282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA337011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2524879Medicaid