Provider Demographics
NPI:1497858765
Name:GODWIN, HERMAN A JR (MD)
Entity Type:Individual
Prefix:
First Name:HERMAN
Middle Name:A
Last Name:GODWIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:BLOWING ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28605-1024
Mailing Address - Country:US
Mailing Address - Phone:828-295-6888
Mailing Address - Fax:
Practice Address - Street 1:184 VIRGINIA ST.
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607
Practice Address - Country:US
Practice Address - Phone:828-262-4332
Practice Address - Fax:828-265-5514
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC36059OtherBLUE CROSS BLUE SHIELD NC
NC8936059Medicaid
NC8936059Medicaid
NC36059OtherBLUE CROSS BLUE SHIELD NC