Healthcare Provider Details

I. General information

NPI: 1548038227
Provider Name (Legal Business Name): JON-KEYTH CRAIG GODWIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4413 TOWN CENTER PKWY
JACKSONVILLE FL
32246-8568
US

IV. Provider business mailing address

201 JOHNSON AVE SW
LIVE OAK FL
32064-4935
US

V. Phone/Fax

Practice location:
  • Phone: 904-998-9822
  • Fax:
Mailing address:
  • Phone: 904-252-8873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: