Provider Demographics
NPI:1164412300
Name:GOODRUM, LINDA A (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:GOODRUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 HIDDEN BROOK LN
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5781
Mailing Address - Country:US
Mailing Address - Phone:281-338-7693
Mailing Address - Fax:281-338-8849
Practice Address - Street 1:251 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 300A
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4213
Practice Address - Country:US
Practice Address - Phone:281-338-7693
Practice Address - Fax:281-338-8849
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4827207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132474109Medicaid
TX176589301Medicaid
TX20-1567092OtherTAX IDENTIFICATION NUMBER
TX20-1567092OtherTAX IDENTIFICATION NUMBER
TX132474109Medicaid
TX00562YMedicare PIN