Provider Demographics
NPI:1225333693
Name:GOODWIN, GARY THOMAS
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:THOMAS
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:
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 7388
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33734-7388
Mailing Address - Country:US
Mailing Address - Phone:727-643-9648
Mailing Address - Fax:
Practice Address - Street 1:600 BYPASS DR
Practice Address - Street 2:SUITE 108
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-5078
Practice Address - Country:US
Practice Address - Phone:727-643-9648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-17
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator