Provider Demographics
NPI:1104803790
Name:GODWIN, SUZANNE G (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:G
Last Name:GODWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9090 REGENCY SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-8119
Mailing Address - Country:US
Mailing Address - Phone:904-724-5576
Mailing Address - Fax:904-724-0721
Practice Address - Street 1:9090 REGENCY SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-8119
Practice Address - Country:US
Practice Address - Phone:904-724-5576
Practice Address - Fax:904-724-0721
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42711207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15866AMedicare PIN
D29537Medicare UPIN