Provider Demographics
NPI:1124024088
Name:GODSEY, RAE JEANNA (DO)
Entity Type:Individual
Prefix:DR
First Name:RAE
Middle Name:JEANNA
Last Name:GODSEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 TUNNEL MILL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9216
Mailing Address - Country:US
Mailing Address - Phone:812-256-0700
Mailing Address - Fax:812-256-0704
Practice Address - Street 1:2100 MARKET ST
Practice Address - Street 2:STE 100
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-9535
Practice Address - Country:US
Practice Address - Phone:812-256-0700
Practice Address - Fax:812-256-0704
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2023-03-07
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
IN02002615A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200441850AMedicaid
7022469OtherAETNA
IN1209485OtherCHA HEALTH
000000301780OtherANTHEM
IN02002615AOtherSTATE LICENSE
15D1020413OtherCLIA
KY64079213Medicaid
907008OtherUSA MCO
INBG7185033OtherDEA
907008OtherUSA MCO
INH37132Medicare UPIN
IN200441850AMedicaid