Provider Demographics
NPI:1629363791
Name:GOODWIN, RUTHRI DIVYA
Entity Type:Individual
Prefix:DR
First Name:RUTHRI
Middle Name:DIVYA
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 MERCY ROAD
Mailing Address - Street 2:ATTN CLINIC CREDENTIALING
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:402-398-6255
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:982055 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-2055
Practice Address - Country:US
Practice Address - Phone:402-559-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6560207R00000X
IAMD42973207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine