Individual
MARK TODD GODENICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
853 N CHURCH ST, SUITE 510, SPARTANBURG, SC 29303-3098
(864) 560-6193
(864) 560-1510
Mailing address
PO BOX 743070, ATLANTA, GA 30374-3070
(864) 560-4304
(864) 560-4413
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
14616
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4455408
AETNA
SC
01
—
A723893365
MEDICARE PIN
SC
01
—
A723895019
MEDICARE PIN
SC
01
—
AA96196067
MEDICARE PIN
SC
01
—
D6334
MEDCOST
SC
05
—
TL3829
—
SC
Enumeration date
05/18/2006
Last updated
01/12/2021
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