Provider Demographics
NPI:1588602734
Name:GOODBAR, TONY R (MD)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:R
Last Name:GOODBAR
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 1:2094 WOODRUFF RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5939
Mailing Address - Country:US
Mailing Address - Phone:864-676-9211
Mailing Address - Fax:864-676-9432
Practice Address - Street 1:2094 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5939
Practice Address - Country:US
Practice Address - Phone:864-676-9211
Practice Address - Fax:864-676-9432
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14711174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC14711OtherSC MED LIC #
SC14711OtherSC MED LIC #