Provider Demographics
NPI:1629218680
Name:GOODSON, RONALD QUINN (SUB IDC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:QUINN
Last Name:GOODSON
Suffix:
Gender:M
Credentials:SUB IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 WARNER HALL DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6103
Mailing Address - Country:US
Mailing Address - Phone:910-265-8823
Mailing Address - Fax:
Practice Address - Street 1:USS NORFOLK SSN-714
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09579-2394
Practice Address - Country:US
Practice Address - Phone:757-443-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman