Healthcare Provider Details

I. General information

NPI: 1881666840
Provider Name (Legal Business Name): GENE GODWIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 W MAIN ST
SALEM VA
24153-3129
US

IV. Provider business mailing address

3716 CHESTERTON ST SW
ROANOKE VA
24018-1804
US

V. Phone/Fax

Practice location:
  • Phone: 540-375-0600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101-017397
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: