Provider Demographics
NPI:1639313851
Name:G P GOODFRIED MD PA
Entity Type:Organization
Organization Name:G P GOODFRIED MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPEDIC SURGEON/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GOODFRIED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-597-5798
Mailing Address - Street 1:1905 S DONNYBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4236
Mailing Address - Country:US
Mailing Address - Phone:903-597-3140
Mailing Address - Fax:903-595-5693
Practice Address - Street 1:1905 S DONNYBROOK AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4236
Practice Address - Country:US
Practice Address - Phone:903-597-3140
Practice Address - Fax:903-595-5693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1592207X00000X
TXPA00823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty