Provider Demographics
NPI:1639125867
Name:GOODWIN, MARK JAMES (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S WASHINGTON ST FL 4
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-7430
Mailing Address - Country:US
Mailing Address - Phone:630-600-0700
Mailing Address - Fax:630-600-0701
Practice Address - Street 1:801 S WASHINGTON ST FL 4
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-7430
Practice Address - Country:US
Practice Address - Phone:630-600-0700
Practice Address - Fax:630-600-0701
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.066770207RC0000X, 207RI0011X
IL036066770207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036066770Medicaid
060015696OtherRAILROAD MEDICARE
ILL76888Medicare ID - Type UnspecifiedLOC
IL756550Medicare ID - Type UnspecifiedLOC 15
IL036066770Medicaid