Provider Demographics
NPI:1598421042
Name:GOODSON, RICHARD L
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:GOODSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 SAINT MARYS LN
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-4968
Mailing Address - Country:US
Mailing Address - Phone:847-387-0006
Mailing Address - Fax:
Practice Address - Street 1:53 SAINT MARYS LN
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-4968
Practice Address - Country:US
Practice Address - Phone:847-387-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health