Healthcare Provider Details

I. General information

NPI: 1255334942
Provider Name (Legal Business Name): EARL R GODWIN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

1720 LOUISIANA BLVD NE STE 401
ALBUQUERQUE NM
87110-7020
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1234
  • Fax: 505-841-1956
Mailing address:
  • Phone: 505-260-4300
  • Fax: 505-260-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number73-129
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: