Basic Information
| Provider Information | |||||||||
| NPI: | 1538198213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODBOUT | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 KEISLER DR | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275117069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197819950 | ||||||||
| FaxNumber: | 9197839950 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 KEISLER DR | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275117069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197819950 | ||||||||
| FaxNumber: | 9197839950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 200300791 | NC | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 2300424 | 01 | NC | UHC | OTHER | 89134PN | 05 | NC | MEDICAID | 3412942 | 01 | CIGNA | OTHER | C6678 | 01 | NC | MEDCOST | OTHER | 134PN | 01 | NC | BCBSNC | OTHER |