Provider Demographics
NPI:1659476232
Name:GOODLOW, KEVIN D (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:GOODLOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5885 GLENRIDGE DR NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5512
Mailing Address - Country:US
Mailing Address - Phone:404-252-7526
Mailing Address - Fax:404-851-1709
Practice Address - Street 1:5885 GLENRIDGE DR NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5512
Practice Address - Country:US
Practice Address - Phone:404-252-7526
Practice Address - Fax:404-851-1709
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA057977207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA761536854AMedicaid
I63669Medicare UPIN
GA115CGQWMedicare ID - Type Unspecified