Provider Demographics
NPI:1760633150
Name:GODWIN, KENNETH A (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:GODWIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:A
Other - Last Name:GODWIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:301 OXFORD VALLEY RD
Mailing Address - Street 2:SUITE 903
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7706
Mailing Address - Country:US
Mailing Address - Phone:267-399-9930
Mailing Address - Fax:267-399-9931
Practice Address - Street 1:301 OXFORD VALLEY RD
Practice Address - Street 2:SUITE 903
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7706
Practice Address - Country:US
Practice Address - Phone:267-399-9930
Practice Address - Fax:267-399-9931
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-04
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0138162086S0122X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00946063OtherRAILROAD MEDICARE
PA3843645000OtherKEYSTONE IBC
PA1026075430001Medicaid
PA30099393OtherKEYSTONE MERCY
PA2632143OtherHIGHMARK BLUE SHIELD
PA3843645000OtherKEYSTONE IBC