Provider Demographics
NPI:1013940964
Name:GODWIN, KEELY B (MD)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:B
Last Name:GODWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1031 W WILLIAMS ST
Mailing Address - Street 2:SUITE106
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-3955
Mailing Address - Country:US
Mailing Address - Phone:919-363-0190
Mailing Address - Fax:919-363-0195
Practice Address - Street 1:1031 W WILLIAMS ST
Practice Address - Street 2:SUITE106
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-3955
Practice Address - Country:US
Practice Address - Phone:919-363-0190
Practice Address - Fax:919-363-0195
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200200328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912910Medicaid
132RUOtherBCBS NC
NC132RUOtherBCBS
NC89132RUMedicaid
7154477OtherAETNA
G89307Medicare UPIN
7154477OtherAETNA
2011314Medicare PIN