Provider Demographics
NPI:1679552780
Name:GOODELL, RUTH C (MD)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:C
Last Name:GOODELL
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 1:1 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-9401
Mailing Address - Country:US
Mailing Address - Phone:317-745-2350
Mailing Address - Fax:
Practice Address - Street 1:1 MANOR DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-9401
Practice Address - Country:US
Practice Address - Phone:317-745-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029055A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100133280BMedicaid
IN100133280AMedicaid
INA42958Medicare UPIN
IN100133280AMedicaid
IN0295890001Medicare PIN
IN180043675Medicare Oscar/Certification
IN341540Medicare PIN
IN100133280BMedicaid