Basic Information
| Provider Information | |||||||||
| NPI: | 1932494630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODWIN | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OGLE | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 691 MURPHY RD STE 107 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894281 | ||||||||
| FaxNumber: | 5417894806 | ||||||||
| Practice Location | |||||||||
| Address1: | 691 MURPHY RD STE 107 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894281 | ||||||||
| FaxNumber: | 5417894806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2011 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 04-40009 | KS | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 55407 | MN | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | MD205416 | OR | N | Allopathic & Osteopathic Physicians | Urology | 2088F0040X | 04-40009 | KS | N | Allopathic & Osteopathic Physicians | Urology | Female Pelvic Medicine and Reconstructive Surgery | 2088F0040X | 55407 | MN | Y | Allopathic & Osteopathic Physicians | Urology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 201162500A | 05 | KS | MEDICAID |