Provider Demographics
NPI:1699738880
Name:GODEJOHN, ANGELA LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:LYNN
Last Name:GODEJOHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 C AVE E
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-4246
Mailing Address - Country:US
Mailing Address - Phone:641-672-3360
Mailing Address - Fax:304-285-7373
Practice Address - Street 1:1229 C AVE E
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-4246
Practice Address - Country:US
Practice Address - Phone:641-672-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26581207Q00000X
IN01055006A207Q00000X
IA40732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC55006AMedicaid
SCP00756632OtherRAILROAD MEDICARE
SC55006AMedicaid