Provider Demographics
NPI:1629165436
Name:GOODIN, JASON A (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:GOODIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 EAST BROADWAY
Mailing Address - Street 2:SUITE 280
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7185
Mailing Address - Country:US
Mailing Address - Phone:573-815-7119
Mailing Address - Fax:573-815-7116
Practice Address - Street 1:1705 EAST BROADWAY
Practice Address - Street 2:SUITE 280
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7185
Practice Address - Country:US
Practice Address - Phone:573-815-7119
Practice Address - Fax:573-815-7116
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006016594207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200011712Medicaid