Provider Demographics
NPI:1194883801
Name:GODWIN, BODIE K (OD)
Entity type:Individual
Prefix:
First Name:BODIE
Middle Name:K
Last Name:GODWIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1368 BAY MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-2069
Mailing Address - Country:US
Mailing Address - Phone:630-289-8013
Mailing Address - Fax:630-213-7407
Practice Address - Street 1:#301 WOODFIELD SHPNG CTR
Practice Address - Street 2:WOODFIELD MALL
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-5012
Practice Address - Country:US
Practice Address - Phone:847-619-2932
Practice Address - Fax:847-619-3967
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008522152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL545496Medicare UPIN