Provider Demographics
NPI:1710001607
Name:GOODWIN, CHARLES JEFFERY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JEFFERY
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3769
Mailing Address - Country:US
Mailing Address - Phone:812-282-3899
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3769
Practice Address - Country:US
Practice Address - Phone:812-282-3899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061089A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01061089AOtherMEDICAL LICENSE
IN200913700Medicaid
000000565585OtherANTHEM FACET
KY41679OtherMEDICAL LICENSE
KY7100059660Medicaid
IN01061089AOtherMEDICAL LICENSE
IN200913700Medicaid