Provider Demographics
NPI:1487626040
Name:GOODWIN, ROBERT GRANT (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GRANT
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:DC
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 751676
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45475-1676
Mailing Address - Country:US
Mailing Address - Phone:937-813-2992
Mailing Address - Fax:937-835-6096
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:SUITE 160
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-813-2992
Practice Address - Fax:937-835-6096
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1982111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0994081Medicaid
311725337027OtherCARESOURCE
OHGO0758464Medicare PIN
U06289Medicare UPIN