Provider Demographics
NPI:1326002817
Name:GOODWIN, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726-4043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5711
Practice Address - Country:US
Practice Address - Phone:617-355-7476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0710162080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7007517Medicaid
MA7007517Medicaid