Provider Demographics
NPI:1417908872
Name:GODFREY, LINCOLN ALEXANDER (DO)
Entity Type:Individual
Prefix:DR
First Name:LINCOLN
Middle Name:ALEXANDER
Last Name:GODFREY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 HIGHWAY 62 E STE 10
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3200
Mailing Address - Country:US
Mailing Address - Phone:870-424-3181
Mailing Address - Fax:870-424-3089
Practice Address - Street 1:624 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2955
Practice Address - Country:US
Practice Address - Phone:870-501-1000
Practice Address - Fax:870-424-3089
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2845207R00000X
ARE2845208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143967003Medicaid
AR143967003Medicaid
AR5L951Medicare ID - Type Unspecified