Provider Demographics
NPI:1124027321
Name:GOODWIN, BRIAN LAWRENCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LAWRENCE
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8175 CARPATHIAN DR
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-4554
Mailing Address - Country:US
Mailing Address - Phone:248-860-5769
Mailing Address - Fax:
Practice Address - Street 1:4737 24 MILE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-3148
Practice Address - Country:US
Practice Address - Phone:248-651-0008
Practice Address - Fax:248-651-6988
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400156213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1906797Medicaid
485505278OtherBX
4661520001OtherDMERK
MI1906797Medicaid
MI5505278Medicare PIN
MI4661520001Medicare NSC