Provider Demographics
NPI:1124019161
Name:GOODPASTURE, JOHN E JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:GOODPASTURE
Suffix:JR
Gender:M
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:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85299-1847
Mailing Address - Country:US
Mailing Address - Phone:480-507-2961
Mailing Address - Fax:480-507-2971
Practice Address - Street 1:1955 W FRYE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6282
Practice Address - Country:US
Practice Address - Phone:480-728-3000
Practice Address - Fax:480-507-2971
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2578207L00000X
AZ47111207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ829085Medicaid
TX157212501Medicaid
AZ829085Medicaid
TXA89053Medicare UPIN
AZA89053Medicare UPIN