Provider Demographics
NPI:1598759391
Name:GOODEN, STEPHEN MARSHALL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARSHALL
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 1:5109 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2691
Mailing Address - Country:US
Mailing Address - Phone:706-825-5166
Mailing Address - Fax:
Practice Address - Street 1:5109 HOLLY LN
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2691
Practice Address - Country:US
Practice Address - Phone:706-825-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033972208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC120176Medicaid
GAD05471Medicare UPIN
02BDBQSMedicare PIN