Provider Demographics
NPI:1285813410
Name:R THAD GOODWIN MD PA
Entity Type:Organization
Organization Name:R THAD GOODWIN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:THAD
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-939-3937
Mailing Address - Street 1:1510 ROYAL PALM SQUARE BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1068
Mailing Address - Country:US
Mailing Address - Phone:239-939-3937
Mailing Address - Fax:239-275-8045
Practice Address - Street 1:1510 ROYAL PALM SQUARE BLVD
Practice Address - Street 2:STE 106
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1068
Practice Address - Country:US
Practice Address - Phone:239-939-3937
Practice Address - Fax:239-275-8045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0037950207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL042931700Medicaid
K5159Medicare PIN
D54488Medicare UPIN