Basic Information
| Provider Information | |||||||||
| NPI: | 1942377015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODOROV | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | FRANCES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103728044 | ||||||||
| FaxNumber: | 4843347026 | ||||||||
| Practice Location | |||||||||
| Address1: | 6TH AVENUE AND SPRUCE STREET | ||||||||
| Address2: | |||||||||
| City: | WEST READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846283637 | ||||||||
| FaxNumber: | 4846288773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 02/07/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS010633L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 101863880 | 05 | PA | MEDICAID |