Provider Demographics
NPI:1619082096
Name:GOODWIN, JANE D (OD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:D
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2303
Mailing Address - Country:US
Mailing Address - Phone:619-466-1560
Mailing Address - Fax:619-446-1692
Practice Address - Street 1:2001 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2303
Practice Address - Country:US
Practice Address - Phone:619-466-1560
Practice Address - Fax:619-446-1692
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6936T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0069360Medicaid
CAWOP6936AMedicare ID - Type Unspecified
CAT95347Medicare UPIN