Provider Demographics
NPI:1750348835
Name:GODBOUT, REGINA M (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:M
Last Name:GODBOUT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:M
Other - Last Name:KINNEY-GODBOUT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2615 E CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-2223
Mailing Address - Country:US
Mailing Address - Phone:555-922-5610
Mailing Address - Fax:
Practice Address - Street 1:2615 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2223
Practice Address - Country:US
Practice Address - Phone:555-922-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110227912OtherRR MEDICARE
WA8270712Medicaid
WA8270712Medicaid
WA112124Medicare PIN