Provider Demographics
NPI:1376854059
Name:GOODWIN, ADAM MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:MATTHEW
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:DO
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 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9769
Practice Address - Street 1:14700 W SAINT TERESA ST STE 300
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-9630
Practice Address - Country:US
Practice Address - Phone:316-274-9450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-36492207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201078150AMedicaid
KS201078150AMedicaid
OK200487350AMedicaid