Provider Demographics
NPI:1184685141
Name:GOODWIN, GLENDA DARLENE (MD)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:DARLENE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1106 WINDFIELD WAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-9360
Mailing Address - Country:US
Mailing Address - Phone:916-941-6500
Mailing Address - Fax:916-691-4300
Practice Address - Street 1:1106 WINDFIELD WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9360
Practice Address - Country:US
Practice Address - Phone:916-941-6500
Practice Address - Fax:916-691-4300
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71660207V00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A716600Medicaid
CA00A716601Medicare ID - Type Unspecified
CA00A716600Medicaid