Provider Demographics
NPI:1255592317
Name:GODWIN, VIVIAN AYOZIEUWA (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:AYOZIEUWA
Last Name:GODWIN
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:HC 61 BOX 30
Mailing Address - Street 2:
Mailing Address - City:TEEC NOS POS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514-9600
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:
Practice Address - Street 1:US HWY 160 & NAVAJO ROUTE 35 - RED MESA
Practice Address - Street 2:
Practice Address - City:TEECNOSPOS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-21
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0327207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CC201OtherBCBS
TX8L16553Medicare PIN
TX202946404Medicaid
TX202946402Medicaid
TX8L16553Medicare PIN
TX202946405Medicaid
TX8CC201OtherBCBS