Provider Demographics
NPI:1568556504
Name:GOODWIN, FREDERICK MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:MARK
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2000 E EDGEWOOD DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3653
Mailing Address - Country:US
Mailing Address - Phone:863-666-3436
Mailing Address - Fax:863-666-7355
Practice Address - Street 1:2000 E EDGEWOOD DR
Practice Address - Street 2:SUITE 112
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3653
Practice Address - Country:US
Practice Address - Phone:863-666-3436
Practice Address - Fax:863-667-3550
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00013382207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
207661OtherAVMED
200018451OtherMEDICARE RAILROAD
0905403OtherUNITED HEALTH CARE
4815734002OtherCIGNA
FL0625534OtherAETNA
FL25133OtherBLUE SHIELD
FL25133ZOtherMEDICARE P-TAN
FL375203800Medicaid
FL25133ZMedicare ID - Type Unspecified
FL375203800Medicaid
200018451OtherMEDICARE RAILROAD