Provider Demographics
NPI:1689780744
Name:GOODWIN, GREGORY R (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:GOODWIN
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 1:100 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-9210
Mailing Address - Country:US
Mailing Address - Phone:417-533-6100
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9210
Practice Address - Country:US
Practice Address - Phone:417-533-6100
Practice Address - Fax:417-533-6173
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102077207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1689780744Medicaid
MO431767432OtherTRICARE
MO132300581Medicare PIN
MO002013019Medicare PIN
MOF47522Medicare UPIN