Provider Demographics
NPI:1598977431
Name:GOODSON, WILLIAM ERNEST
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ERNEST
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 1:11258 STATE ROUTE 348
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8971
Mailing Address - Country:US
Mailing Address - Phone:740-259-5497
Mailing Address - Fax:740-259-5497
Practice Address - Street 1:11258 STATE ROUTE 348
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-8971
Practice Address - Country:US
Practice Address - Phone:740-259-5497
Practice Address - Fax:740-259-5497
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0951993Medicaid