1497074363 NPI number — GLENDA GOODWIN MD INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497074363 NPI number — GLENDA GOODWIN MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLENDA GOODWIN MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497074363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9281 OFFICE PARK CIR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95758-8068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-691-4300
Provider Business Mailing Address Fax Number:
916-691-4302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9281 OFFICE PARK CIR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-8068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-691-4300
Provider Business Practice Location Address Fax Number:
916-691-4302
Provider Enumeration Date:
05/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GOODWIN
Authorized Official First Name:
GLENDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
916-691-4301

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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