Provider Demographics
NPI:1790796316
Name:GODO, CHARLES MAWULI (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MAWULI
Last Name:GODO
Suffix:
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 1:3000 HYDRANGEA AVE
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4939
Mailing Address - Country:US
Mailing Address - Phone:312-593-6700
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-288-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0092207R00000X
KYTP516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI76343501Medicaid
TXM0092OtherTEXAS STATE MEDICAL LIC.
TXI 31135Medicare UPIN