Provider Demographics
NPI:1255308177
Name:GOODEN, JOSHUA J (OD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:J
Last Name:GOODEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 712
Mailing Address - Street 2:104 ALBERT AVE.
Mailing Address - City:SCOTT CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67871-1216
Mailing Address - Country:US
Mailing Address - Phone:620-872-0040
Mailing Address - Fax:620-872-0041
Practice Address - Street 1:104 ALBERT AVE.
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:KS
Practice Address - Zip Code:67871-1216
Practice Address - Country:US
Practice Address - Phone:620-872-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1528-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS651038OtherBLUE CROSS & BLUE SHIELD
KS410039905OtherRR MEDICARE
KS100325510CMedicaid
KSU72457Medicare UPIN
KS410039906Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KS1247280001Medicare ID - Type UnspecifiedREGION C (DMERC)
KS100325510CMedicaid
KS1247280001Medicare NSC