Provider Demographics
NPI:1558353748
Name:GOODWIN, ROBIN THAD (MD)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:THAD
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1510 ROYAL PALM SQUARE BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1068
Mailing Address - Country:US
Mailing Address - Phone:239-939-3937
Mailing Address - Fax:239-275-8045
Practice Address - Street 1:1510 ROYAL PALM SQUARE BLVD
Practice Address - Street 2:STE 106
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1068
Practice Address - Country:US
Practice Address - Phone:239-939-3937
Practice Address - Fax:239-275-8045
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0037950207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL042931700Medicaid
FL042931700Medicaid
D54488Medicare UPIN