Healthcare Provider Details

I. General information

NPI: 1053232512
Provider Name (Legal Business Name): DWIGHT DAVID GODWIN NIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MULLIGAN DR
FLANDERS NJ
07836-4742
US

IV. Provider business mailing address

16 MULLIGAN DR
FLANDERS NJ
07836-4742
US

V. Phone/Fax

Practice location:
  • Phone: 585-330-3201
  • Fax:
Mailing address:
  • Phone: 585-330-3201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number20014
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: