Provider Demographics
NPI:1871687327
Name:GODFREY, WANDA LEE (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LEE
Last Name:GODFREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 CRESCENTCOMMONS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8102
Mailing Address - Country:US
Mailing Address - Phone:919-803-3707
Mailing Address - Fax:
Practice Address - Street 1:115 CRESCENTCOMMONS DR STE 100
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8102
Practice Address - Country:US
Practice Address - Phone:919-803-3707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93-00704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
36032OtherBCBS PIN
NC8936023Medicaid
P00157587OtherMEDICARE RAILROAD
NC93-00704OtherSTATE LISCENCE #
NC8936023Medicaid
36032OtherBCBS PIN