Provider Demographics
NPI:1699769190
Name:GODOSHIAN, CHARLES G (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:GODOSHIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27177 LAHSER RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-4714
Mailing Address - Country:US
Mailing Address - Phone:248-353-0882
Mailing Address - Fax:248-353-0883
Practice Address - Street 1:27177 LAHSER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4714
Practice Address - Country:US
Practice Address - Phone:248-353-0882
Practice Address - Fax:248-353-0883
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MICG046652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1106346941OtherBLUE CROSS BLUE SHIELD
MI1731411Medicaid
MI0P19960Medicare ID - Type Unspecified
MI1106346941OtherBLUE CROSS BLUE SHIELD
MIP19960001Medicare ID - Type Unspecified