Provider Demographics
NPI:1265837488
Name:GOODWIN, VERNON
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:
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 1:102 DEERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2516
Mailing Address - Country:US
Mailing Address - Phone:541-778-2050
Mailing Address - Fax:
Practice Address - Street 1:102 DEERWOOD DR
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2516
Practice Address - Country:US
Practice Address - Phone:541-778-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman