Provider Demographics
NPI:1669482824
Name:GOODYEAR, CONSTANCE M (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:M
Last Name:GOODYEAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-928-4412
Mailing Address - Fax:601-928-4792
Practice Address - Street 1:805 HALL ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2110
Practice Address - Country:US
Practice Address - Phone:601-928-4412
Practice Address - Fax:601-928-4792
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00120058OtherRAILROAD MEDICARE
MS00116736Medicaid
MS640507572BBOtherAMERICAN ADMIN GROUP
P00120058OtherRAILROAD MEDICARE
MS00116736Medicaid