Provider Demographics
NPI:1164573515
Name:GOODFELLOW, KEITH G (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
Last Name:GOODFELLOW
Suffix:
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 321359
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-1359
Mailing Address - Country:US
Mailing Address - Phone:601-936-1395
Mailing Address - Fax:601-936-1260
Practice Address - Street 1:147 REYNOIR ST STE 105
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530
Practice Address - Country:US
Practice Address - Phone:228-436-6674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13840207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06474210Medicaid
MS512I160022Medicare PIN
MS160000305Medicare PIN
MS06474210Medicaid