Provider Demographics
NPI:1861572000
Name:GODIALI, VASSO G (MD)
Entity type:Individual
Prefix:DR
First Name:VASSO
Middle Name:G
Last Name:GODIALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708
Mailing Address - Country:US
Mailing Address - Phone:989-893-8361
Mailing Address - Fax:989-893-3528
Practice Address - Street 1:2010 15TH ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708
Practice Address - Country:US
Practice Address - Phone:989-893-8361
Practice Address - Fax:989-893-3528
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVG0655562086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11277067OtherCAQH
MI0200910161OtherBCBS
MI4540351Medicaid
H58622Medicare UPIN
MI4540351Medicaid