Provider Demographics
NPI:1437228194
Name:GOODWIN, MALCOLM NOYES JR (M D)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:NOYES
Last Name:GOODWIN
Suffix:JR
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 WOODLAND CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3500
Mailing Address - Country:US
Mailing Address - Phone:618-632-6164
Mailing Address - Fax:618-632-0186
Practice Address - Street 1:206 WOODLAND CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3500
Practice Address - Country:US
Practice Address - Phone:618-632-6164
Practice Address - Fax:618-632-0186
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD 102549207ZC0500X, 207ZF0201X, 207ZP0102X
IL207ZC0500X, 207ZF0201X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Not Answered207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF55567Medicare UPIN