Healthcare Provider Details

I. General information

NPI: 1255592317
Provider Name (Legal Business Name): VIVIAN AYOZIEUWA GODWIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2008
Last Update Date: 08/10/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 160 & NAVAJO ROUTE 35 - RED MESA
TEECNOSPOS AZ
86514
US

IV. Provider business mailing address

HC 61 BOX 30
TEEC NOS POS AZ
86514-9600
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5000
  • Fax:
Mailing address:
  • Phone: 928-656-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN0327
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: