Provider Demographics
NPI:1962876367
Name:GODWIN, RANDY W I (DISPENSING OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:W
Last Name:GODWIN
Suffix:I
Gender:M
Credentials:DISPENSING OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 N BRIGHTLEAF BLVD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4229
Mailing Address - Country:US
Mailing Address - Phone:919-934-1272
Mailing Address - Fax:919-934-1273
Practice Address - Street 1:1233 N BRIGHTLEAF BLVD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4229
Practice Address - Country:US
Practice Address - Phone:919-934-1272
Practice Address - Fax:919-934-1273
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1508156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC47-5024935Medicaid