Provider Demographics
NPI:1417989351
Name:GOODALL, DAVID CHARLES
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHARLES
Last Name:GOODALL
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 1:1025 10TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-8703
Mailing Address - Country:US
Mailing Address - Phone:218-246-8275
Mailing Address - Fax:218-246-8279
Practice Address - Street 1:1025 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-8703
Practice Address - Country:US
Practice Address - Phone:218-246-8275
Practice Address - Fax:218-246-8279
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D48592Medicare UPIN
MN080008916Medicare PIN