Provider Demographics
NPI:1841753928
Name:GODWIN, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GODWIN
Suffix:
Gender:M
Credentials:
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 451
Mailing Address - Street 2:
Mailing Address - City:KEEN MOUNTAIN
Mailing Address - State:VA
Mailing Address - Zip Code:24624-0451
Mailing Address - Country:US
Mailing Address - Phone:443-640-5748
Mailing Address - Fax:
Practice Address - Street 1:1060 DRAGON RD
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:VA
Practice Address - Zip Code:24631-9210
Practice Address - Country:US
Practice Address - Phone:866-935-7350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0203018071390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program