Provider Demographics
NPI:1730186867
Name:GODNIG, EDWARD CARL (OD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CARL
Last Name:GODNIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 E PARKS HWY STE A
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7039
Mailing Address - Country:US
Mailing Address - Phone:907-376-3917
Mailing Address - Fax:907-376-3967
Practice Address - Street 1:285 E PARKS HWY STE A
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7039
Practice Address - Country:US
Practice Address - Phone:907-376-3917
Practice Address - Fax:907-376-3967
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD4478Medicaid
AKOD4478Medicaid