MEDICARE: MIDTOWN OPTOMETRY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1023754298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDTOWN OPTOMETRY PLLC

Provider Business Mailing Address
First Line	:	4109 WAKE FOREST RD STE 10
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-2510
Country	:	US
Telephone Number	:	984-213-8863
Fax Number	:	984-300-5241

Provider Business Practice Location Address
First Line	:	4109 WAKE FOREST RD STE 10
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-2510
Country	:	US
Telephone Number	:	984-213-8863
Fax Number	:

Authorized Official
Title or Position	:	OD/PRESIDENT
Name	:	DR. KEEL GODWIN
Credential	:	OD
Telephone Number	:	919-270-6368

Provider Enumeration Date	:	05/10/2022
Last Update Date	:	11/25/2024

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