Provider Demographics
NPI:1407964158
Name:GOODWIN, GRADY G (MD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:G
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 1:3500 GASTON AVE
Mailing Address - Street 2:4 ROBERTS
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2017
Mailing Address - Country:US
Mailing Address - Phone:214-820-3000
Mailing Address - Fax:214-820-3022
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:4 ROBERTS
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2017
Practice Address - Country:US
Practice Address - Phone:214-820-3000
Practice Address - Fax:214-820-3022
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4160207R00000X
TXM4106208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G0895OtherBCBS
TX184835001Medicaid
TX184835002Medicaid
TX8CZ855OtherBCBSTX
TX184835001Medicaid
TXTXB132522Medicare PIN
TX8G0895OtherBCBS
TX8CZ855OtherBCBSTX