Provider Demographics
NPI:1659473007
Name:GOODEAR, GREGORY C (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:GOODEAR
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 1:2671 ELMS PLANTATION BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9165
Mailing Address - Country:US
Mailing Address - Phone:843-797-6800
Mailing Address - Fax:843-797-6825
Practice Address - Street 1:2671 ELMS PLANTATION BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9165
Practice Address - Country:US
Practice Address - Phone:843-797-6800
Practice Address - Fax:843-797-6825
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28430207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC284301Medicaid
SC284301Medicaid
SCH44719Medicare UPIN