Provider Demographics
NPI:1639266950
Name:GOODELL, THOMAS PERRY (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PERRY
Last Name:GOODELL
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 1:400 BENEDICTA AVE
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2099
Mailing Address - Country:US
Mailing Address - Phone:719-846-2206
Mailing Address - Fax:719-845-0663
Practice Address - Street 1:400 BENEDICTA AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2099
Practice Address - Country:US
Practice Address - Phone:719-846-2206
Practice Address - Fax:719-845-0663
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6971A207Q00000X
CO46411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO822753335Medicaid
WY119222100Medicaid
WYD85804Medicare UPIN
WY119222100Medicaid
COCOA103134Medicare PIN