Provider Demographics
NPI:1225017288
Name:GOODKIN, PETER E (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:GOODKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PETER
Other - Middle Name:E
Other - Last Name:GOODKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PC
Mailing Address - Street 1:9775 SE SUNNYSIDE ROAD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5724
Mailing Address - Country:US
Mailing Address - Phone:503-654-7546
Mailing Address - Fax:503-786-3542
Practice Address - Street 1:9775 SE SUNNYSIDE ROAD
Practice Address - Street 2:SUITE 500
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5724
Practice Address - Country:US
Practice Address - Phone:503-654-7546
Practice Address - Fax:503-786-3542
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09756207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR057794Medicaid
OR057794Medicaid
C92739Medicare UPIN