Provider Demographics
NPI:1457312050
Name:GOODWIN, RUSSEL L (MD)
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:L
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 1:303 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2004
Mailing Address - Country:US
Mailing Address - Phone:859-236-1080
Mailing Address - Fax:859-236-1862
Practice Address - Street 1:303 S 4TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2004
Practice Address - Country:US
Practice Address - Phone:859-236-1080
Practice Address - Fax:859-236-1862
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16364208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64163645Medicaid
KYC70703Medicare UPIN
KY64163645Medicaid