Provider Demographics
NPI:1689667420
Name:GOODSELL, CRAIG W (DO)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:W
Last Name:GOODSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TOWN PLZ # 407
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5104
Mailing Address - Country:US
Mailing Address - Phone:719-648-5678
Mailing Address - Fax:
Practice Address - Street 1:575 RIVERGATE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7487
Practice Address - Country:US
Practice Address - Phone:719-648-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02628207L00000X
CODR.0045552207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64002223Medicaid
KYF31842Medicare UPIN
KYF31842Medicare UPIN