Provider Demographics
NPI:1548038227
Name:GODWIN, JON-KEYTH CRAIG (OD)
Entity type:Individual
Prefix:
First Name:JON-KEYTH
Middle Name:CRAIG
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 1:201 JOHNSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-4935
Mailing Address - Country:US
Mailing Address - Phone:904-252-8873
Mailing Address - Fax:
Practice Address - Street 1:4413 TOWN CENTER PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8568
Practice Address - Country:US
Practice Address - Phone:904-998-9822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program