Provider Demographics
NPI:1558322016
Name:GOODEN, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:GOODEN
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 1:7001 ROGERS AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4073
Mailing Address - Country:US
Mailing Address - Phone:479-573-3101
Mailing Address - Fax:479-573-3102
Practice Address - Street 1:7001 ROGERS AVE STE 600
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4073
Practice Address - Country:US
Practice Address - Phone:479-573-3101
Practice Address - Fax:479-573-3102
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29487208600000X
ARE-6422208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200298850AMedicaid
AR5AE29Medicare PIN