Provider Demographics
NPI:1962563536
Name:GODFREY, CHARLES BRIEN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRIEN
Last Name:GODFREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:501 HIGHWAY 13 E
Mailing Address - Street 2:SUITE 116
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2884
Mailing Address - Country:US
Mailing Address - Phone:651-365-3606
Mailing Address - Fax:651-681-9317
Practice Address - Street 1:501 HIGHWAY 13 E
Practice Address - Street 2:SUITE 116
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2884
Practice Address - Country:US
Practice Address - Phone:651-365-3606
Practice Address - Fax:651-681-9317
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN260582084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND73257Medicare UPIN