Basic Information
| Provider Information | |||||||||
| NPI: | 1164483483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODWIN | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 609 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365999257 | ||||||||
| FaxNumber: | 3365991593 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365999257 | ||||||||
| FaxNumber: | 3365991593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 02/22/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 9501254 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 9501254 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 891005R | 05 | NC | MEDICAID |