Provider Demographics
NPI:1023165503
Name:GODEREZ, BRUCE I (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:I
Last Name:GODEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 380
Mailing Address - Street 2:8 RIVER DR.
Mailing Address - City:HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01035-0380
Mailing Address - Country:US
Mailing Address - Phone:413-582-1839
Mailing Address - Fax:413-582-6855
Practice Address - Street 1:8 RIVER DR
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-3540
Practice Address - Country:US
Practice Address - Phone:413-582-1839
Practice Address - Fax:413-582-6855
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA507622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3037746Medicaid
MAJ08122Medicare UPIN